Basic Information
| Provider Information | |||||||||
| NPI: | 1982609244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 56765 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063860 | ||||||||
| FaxNumber: | 6024066132 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063874 | ||||||||
| FaxNumber: | 6024064011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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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 | 174400000X | 21323 | AZ | N | Other Service Providers | Specialist | 2086S0127X | 21323 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 142042 | 05 | AZ | MEDICAID |