Individual
HOLLY RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
18210 LA GRANGE RD, SUITE 205, TINLEY PARK, IL 60487-7722
(708) 478-7800
(708) 478-7870
Mailing address
18210 LA GRANGE RD STE 205, TINLEY PARK, IL 60487-7725
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036120579
IL
390200000X
Student in an Organized Health Care Education/Training Program
2005017735
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036120579
—
IL
Enumeration date
06/12/2007
Last updated
02/23/2022
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