Basic Information
| Provider Information | |||||||||
| NPI: | 1417318361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 294 SUMMAR DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312658220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16815 W BELL RD | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853742101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028336900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2016 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 3749 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 008645 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.