Basic Information
| Provider Information | |||||||||
| NPI: | 1447206933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MIAMISBURG CENTERVILLE RD STE 207 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375602011 | ||||||||
| FaxNumber: | 9375602012 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 MIAMISBURG CENTERVILLE RD | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453427615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375602011 | ||||||||
| FaxNumber: | 9375602012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35073039 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2169380 | 05 | OH | MEDICAID |