Provider Demographics
NPI:1902812613
Name:RUSSELL, CHRISTOPHER THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:THOMAS
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 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050148332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
430954380CAPOtherMERCY HEALTH PLAN
MO185214OtherMO BLUE CROSS BLUE SHIELD
716349OtherHEALTHLINK
MO207361304Medicaid
IL036-113584OtherIL BLUE CROSS BLUE SHIELD
063896OtherHEALTH ALLIANCE
H62246Medicare UPIN
ILK22544Medicare ID - Type UnspecifiedIL MEDICARE
ILP00280886Medicare ID - Type UnspecifiedIL RAILROAD MEDICARE
MO207361304Medicaid
063896OtherHEALTH ALLIANCE