Individual
MARK W RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 E MEDICAL CENTER DR, 11TH FLOOR CS MOTT CHILDRENS HOSPITAL ROOM 661, ANN ARBOR, MI 48109-5204
(734) 764-5176
Mailing address
3621 S STATE ST, 700 KMS PLACE, ANN ARBOR, MI 48108
(734) 936-2047
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
4301060392
MI
2080P0202X
Pediatric Cardiology Physician
Primary
4301060392
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3226763
—
MI
Enumeration date
07/31/2006
Last updated
04/29/2013
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