Basic Information
| Provider Information | |||||||||
| NPI: | 1316428931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH RUSS MD, PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HOLLAND STE 101 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 490 S FARRELL DR STE C106 | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922627962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604166773 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUSS | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9495882190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.