Provider Demographics
NPI:1962527655
Name:DEBORAH L RUSSELL MD PLLC
Entity type:Organization
Organization Name:DEBORAH L RUSSELL MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-791-9100
Mailing Address - Street 1:4177 FASHION SQUARE BLVD.
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5216
Mailing Address - Country:US
Mailing Address - Phone:989-791-9100
Mailing Address - Fax:989-791-6746
Practice Address - Street 1:4177 FASHION SQUARE BLVD.
Practice Address - Street 2:SUITE # 1
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-5216
Practice Address - Country:US
Practice Address - Phone:989-791-9100
Practice Address - Fax:989-791-6746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053500207V00000X
207VG0400X
MI4704246844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G310050OtherBCBSM
MI3170069Medicaid
MIOM14080002Medicare ID - Type UnspecifiedRUSSELL MEDICARE
MIOP18760Medicare UPIN
MI3170069Medicaid
OM14080Medicare PIN