Basic Information
| Provider Information | |||||||||
| NPI: | 1578551008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST STE 800 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025835948 | ||||||||
| FaxNumber: | 5025831804 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | STE 902 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025835948 | ||||||||
| FaxNumber: | 5025831804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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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 | 208600000X | 24718 | KY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | K209590-KOHMG | 01 | KY | KY MEDICARE | OTHER | 64247182 | 05 | KY | MEDICAID |