Basic Information
| Provider Information | |||||||||
| NPI: | 1578503785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKWELL | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | ANESTHESIA ASSOCIATES OF NAPLES, PA | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341193900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393044862 | ||||||||
| FaxNumber: | 2393045157 | ||||||||
| Practice Location | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | ANESTHESIA ASSOCIATES OF NAPLES, PA | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341193900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393044862 | ||||||||
| FaxNumber: | 2393045157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20147 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME98102 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 010033CG86101 | 01 | AL | SECTION 1011 | OTHER | 050065291 | 01 | AL | RAILROAD MEDICARE | OTHER | 42512 | 01 | AL | HEALTHSPRING | OTHER | G86101 | 01 | AL | VIVA | OTHER | 000007604 | 01 | AL | BLUE CROSS | OTHER | 009916165 | 05 | AL | MEDICAID | 000007602 | 01 | AL | BLUE CROSS | OTHER | 000007609 | 05 | AL | MEDICAID | 000007609 | 01 | AL | BLUE CROSS | OTHER | 06857292 | 01 | MS | MISSISSIPPI MEDICAID | OTHER | 009916175 | 05 | AL | MEDICAID |