# RENEE J RUSSELL MD INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Grand Lake Primary Care
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316092182
- **Authorized official:** DR. RENEE JEAN RUSSELL M.D. (PROVIDER)
- **Authorized official phone:** (918) 786-3100

## Contact information

- **Practice address:** 900 E 13TH ST, SUITE 104, GROVE, OK 74344-2975
- **Practice address phone:** (918) 786-3100
- **Practice address fax:** (918) 786-3108
- **Mailing address:** 1110 NEO LOOP, GROVE, OK 74344-6046
- **Mailing address phone:** (918) 786-3100
- **Mailing address fax:** (918) 786-3108

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 22021 | OK | Yes |

## Other

- **Enumeration date:** 01/24/2007
- **Last updated:** 11/11/2016