Provider Demographics
NPI:1447218920
Name:RUSSELL, STEPHEN WILBON (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WILBON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:
Practice Address - Street 1:619 19TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-080853207R00000X, 208000000X
AL28087207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051110649OtherBLUE CROSS
OH2467736Medicaid
AL108956Medicaid
AL125496Medicaid
AL051114567OtherBLUE CROSS
AL127053Medicaid
AL51103180OtherBLUE CROSS
IN200469750Medicaid
ALP00653613OtherRAILROAD MEDICARE
AL009943077Medicaid
AL051541057OtherBLUE CROSS
AL116248Medicaid
KY64078314Medicaid
AL051559036Medicare PIN
AL051541057OtherBLUE CROSS
AL125496Medicaid
I05557Medicare UPIN