Basic Information
| Provider Information | |||||||||
| NPI: | 1750371308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CECIL | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | N.A. | ||||||||
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| Credential: | M.D.,PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5010 STATE HIGHWAY 30 STE 205 | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188422663 | ||||||||
| FaxNumber: | 5188424861 | ||||||||
| Practice Location | |||||||||
| Address1: | 5010 STATE HIGHWAY 30 | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188422663 | ||||||||
| FaxNumber: | 5188424861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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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 | 207X00000X | 160800-1 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00867616 | 05 | NY | MEDICAID |