Basic Information
| Provider Information | |||||||||
| NPI: | 1417937723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 2104 JOLLY RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488646043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179751400 | ||||||||
| FaxNumber: | 5179751405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101010708 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0700083 | 01 | MI | PHYSICIANS HEALTH PLAN | OTHER | 160C311260 | 01 | MI | BLUE CHOICE | OTHER | 160C311260 | 01 | MI | BLUE CARE NETWORK | OTHER | 1006244 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | E68082 | 01 | MI | HEALTH NET FEDERAL SERVIC | OTHER | 4460493 | 05 | MI | MEDICAID | 160C311260 | 01 | MI | COMMUNITY BLUE PPO | OTHER | 1006244 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 1652300205 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 160C311260 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |