Basic Information
| Provider Information | |||||||||
| NPI: | 1558454801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417856 | ||||||||
| FaxNumber: | 3218436432 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417856 | ||||||||
| FaxNumber: | 3218436432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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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 | 207R00000X | 39076 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 39076 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 39076 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | ME114533 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | ME114533 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008144900 | 05 | FL | MEDICAID | ME114533 | 01 | FL | MEDICAL LICENSE | OTHER |