1376595991 NPI number — DR. RUSS DEACON BIRDWELL M.D.

Table of content: JENNIFER MARIE KIEFER MSW (NPI 1487842290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376595991 NPI number — DR. RUSS DEACON BIRDWELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRDWELL
Provider First Name:
RUSS
Provider Middle Name:
DEACON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376595991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 SHIRE BLVD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75082-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-487-6400
Provider Business Mailing Address Fax Number:
972-487-1686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 SHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
RICHARDSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75082-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-487-6400
Provider Business Practice Location Address Fax Number:
972-487-1686
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  G71405 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105418103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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