Basic Information
| Provider Information | |||||||||
| NPI: | 1962527655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEBORAH L RUSSELL MD PLLC | ||||||||
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| OtherOrganizationName: | DEBORAH L RUSSELL MD AND PAUL A MEYER MD PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4177 FASHION SQUARE BLVD. | ||||||||
| Address2: | SUITE # 1 | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486035216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897919100 | ||||||||
| FaxNumber: | 9897916746 | ||||||||
| Practice Location | |||||||||
| Address1: | 4177 FASHION SQUARE BLVD. | ||||||||
| Address2: | SUITE # 1 | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486035216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897919100 | ||||||||
| FaxNumber: | 9897916746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9897919100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301053500 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LF0000X | 4704246844 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 700G310050 | 01 | MI | BCBSM | OTHER | 3170069 | 05 | MI | MEDICAID |