Organization
DEIDRE J. RUSSELL, M.D.,LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DEIDRE RUSSELL MD (PHYSICIAN)
(334) 875-2134
Entity
Organization
Contact information
Practice address
203 VAUGHAN MEMORIAL DR, SELMA, AL 36701-6950
(334) 875-2134
(334) 875-4331
Mailing address
PO BOX 1470, SELMA, AL 36702-1470
(334) 875-2134
(334) 875-4331
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
00019979
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
09475
BLUE CROSS BLUE SHIELD
AL
Enumeration date
05/27/2006
Last updated
08/22/2020
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