Basic Information
| Provider Information | |||||||||
| NPI: | 1104237130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
| FaxNumber: | 7796967342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 CHARLES ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796968800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2014 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-011657 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 041.368559 | IL | N | Nursing Service Providers | Registered Nurse | 363L00000X | 277-000310 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.