Basic Information
| Provider Information | |||||||||
| NPI: | 1316084965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20665 BLUE FOX WAY | ||||||||
| Address2: | |||||||||
| City: | HOWARD CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313400112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 LINDEN ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BIG RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493071879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317960010 | ||||||||
| FaxNumber: | 2317962496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901004360 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0E40038 | 01 | MI | BCBSM | OTHER | CG0293 | 01 | MEDICARE RAILROAD | OTHER |