Provider Demographics
NPI:1902120819
Name:RUSSELL, ANDREW COLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:COLIN
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 1:6800 ILLINOIS 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-5711
Mailing Address - Fax:
Practice Address - Street 1:28 COUNTRY CLUB VW
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3626
Practice Address - Country:US
Practice Address - Phone:573-424-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012023819207P00000X
IL036.134694207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine