Basic Information
| Provider Information | |||||||||
| NPI: | 1902120819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | COLIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 ILLINOIS 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182885711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 28 COUNTRY CLUB VW | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620253626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734249110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2012023819 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036.134694 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.