Basic Information
| Provider Information | |||||||||
| NPI: | 1407836653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEY | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42645 GARFIELD RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862860050 | ||||||||
| FaxNumber: | 5862860880 | ||||||||
| Practice Location | |||||||||
| Address1: | 42645 GARFIELD RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862860050 | ||||||||
| FaxNumber: | 5862860880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4310142875 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4373665 | 05 | MI | MEDICAID |