Individual
ROBERT T RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1404 EASTLAND DR STE 209, BLOOMINGTON, IL 61701-7904
(309) 662-3277
(309) 663-0845
Mailing address
1404 EASTLAND DR STE 209, BLOOMINGTON, IL 61701-7904
(309) 662-3277
(309) 663-0845
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
036082417
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036082417
—
IL
01
—
05700224
BLU CROSS BLUE SHIELD
—
Enumeration date
08/28/2006
Last updated
10/20/2015
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