Provider Demographics
NPI:1730273160
Name:RUSSELL, LESLIE A (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 15TH AVE S SUITE 204
Mailing Address - Street 2:RADILOGY MONTANA, PC
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-727-0484
Mailing Address - Fax:406-453-9504
Practice Address - Street 1:401 15TH AVE S SUITE 204
Practice Address - Street 2:RADILOGY MONTANA, PC
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-727-0484
Practice Address - Fax:406-453-9504
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT73452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0100436Medicaid
MT0100436Medicaid