Basic Information
| Provider Information | |||||||||
| NPI: | 1528015559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSSELL PERRY MD, A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3222 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945580293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072617824 | ||||||||
| FaxNumber: | 7072563508 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 RIVER DR | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954375403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079614665 | ||||||||
| FaxNumber: | 7079614780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | MYRON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7072617880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G428120 | 05 | CA | MEDICAID | DA6000 | 01 | RAILROAD MEDICARE PIN | OTHER |