Basic Information
| Provider Information | |||||||||
| NPI: | 1821074162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815123 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 WEST HIGH STREET | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458015901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192288950 | ||||||||
| FaxNumber: | 4192247904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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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 | 208800000X | 35045028 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 06151 | 01 | OH | PARAMOUNT ADVANTAGE MEDICAID | OTHER | 0437932 | 05 | OH | MEDICAID | 4218612 | 01 | OH | AETNA | OTHER | 735041 | 01 | OH | BUCKEYE MEDICAID | OTHER | 3358254 | 01 | OH | CIGNA | OTHER | 000000596289 | 01 | OH | ANTHEM PIN | OTHER | 262788491032 | 01 | OH | CARESOURCE MEDICAID | OTHER |