Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2082S0105X | Plastic Hand Surgeon | 036061657 | IL |
N | 208200000X | Surgeon | 036061657 | IL |
N | 208600000X | Surgeon | 036061657 | IL |
Y | 2086S0122X | Plastic and Reconstructive Surgery | 036061657 | IL |
NPI | 1700823879 |
---|---|
Provider Name | Robert C Russell |
First Address | Springfield, IL 62702-5185 |
Second Address | Springfield, IL 62702-5185 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2006 |
Last Update Date | 21/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036061657 | (05) | IL |
D14524 | (02) | IL |