Basic Information
| Provider Information | |||||||||
| NPI: | 1548234032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LARRY J RUSSELL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 BALSAM RD | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286934431 | ||||||||
| FaxNumber: | 8286934871 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 BALSAM RD | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286934431 | ||||||||
| FaxNumber: | 8286934871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8286934431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NPB019 | 05 | SC | MEDICAID | 8901249 | 05 | NC | MEDICAID |