Basic Information
| Provider Information | |||||||||
| NPI: | 1396835641 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBERT C RUSSELL M D S C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROBERT C RUSSELL M D S C | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E CARPENTER ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175230808 | ||||||||
| FaxNumber: | 2177535324 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E CARPENTER ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175230808 | ||||||||
| FaxNumber: | 2177535324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 03/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNERPRESIDEN | ||||||||
| AuthorizedOfficialTelephone: | 2175230808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036061657 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036061657 | 05 | IL | MEDICAID |