Provider Demographics
NPI:1174727267
Name:RUSSELL, HOLLY (MD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18210 LA GRANGE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18210 LA GRANGE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7722
Practice Address - Country:US
Practice Address - Phone:708-478-7800
Practice Address - Fax:708-478-7870
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005017735390200000X
IL036120579208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120579Medicaid