Basic Information
| Provider Information | |||||||||
| NPI: | 1184691222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MARY LOUISE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | P.O.BOX 9196 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042933909 | ||||||||
| FaxNumber: | 3042937042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 SHADY AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152171350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124202270 | ||||||||
| FaxNumber: | 4124204450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD044119E | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208100000X | MD044119E | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 29378 | WV | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1170159 | 05 | PA | MEDICAID |