| Name: | Deidre J. Russell, M.D., LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 30 Dec 2003 (21 years ago) |
| Date of dissolution: | 14 Nov 2017 |
| Entity Number: | 000-696-271 |
| Register Number: | 000696271 |
| County: | Dallas |
| Place of Formation: | Dallas County |
| Principal Address: | SELMA, AL |
| Registered Office Street Address: | 203 VAUGHAN MEMORIAL DRSELMA, AL 36701 |
| Registered Office Street Address ZIP Code: | 36701 |
Activities
MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003863846 | 2006-05-27 | 2020-08-22 | PO BOX 1470, SELMA, AL, 367021470, US | 203 VAUGHAN MEMORIAL DR, SELMA, AL, 367016950, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 334-875-2134 |
| Fax | 3348754331 |
Authorized person
| Name | DR. DEIDRE RUSSELL |
| Role | PHYSICIAN |
| Phone | 3348752134 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 00019979 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 09475 |
| State | AL |
| Name | Role |
|---|---|
| RUSSELL, DEIDRE J | Agent |
| Name | Role |
|---|---|
| RUSSELL, DEIDRE J | Member |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
