Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 31614 | AL |
NPI | 1477600328 |
---|---|
Provider Name | Robert Thomason Russell |
First Address | Birmingham, AL 35233-1711 |
Second Address | Birmingham, AL 35233-1711 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 12/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02875872 | (05) | MS |
140016 | (05) | AL |
140183 | (05) | AL |