Provider Demographics
NPI:1861423790
Name:JOHNSON, RUSSELL TALMAGE (ATC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TALMAGE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 OLD LAKE CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8152
Mailing Address - Country:US
Mailing Address - Phone:662-236-2368
Mailing Address - Fax:
Practice Address - Street 1:1190 S 18TH STREET EXT
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5378
Practice Address - Country:US
Practice Address - Phone:662-234-0424
Practice Address - Fax:662-234-0485
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT02172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer