Organization
RENEE J RUSSELL MD INC
Active
Other names
Grand Lake Primary Care
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RENEE JEAN RUSSELL M.D. (PROVIDER)
(918) 786-3100
Entity
Organization
Contact information
Practice address
900 E 13TH ST, SUITE 104, GROVE, OK 74344-2975
(918) 786-3100
(918) 786-3108
Mailing address
1110 NEO LOOP, GROVE, OK 74344-6046
(918) 786-3100
(918) 786-3108
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
22021
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100017290D
—
OK
Enumeration date
01/24/2007
Last updated
11/11/2016
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