1437141041 NPI number — MR. CHARLES BYROM RUSSEY MD

Table of content: MR. CHARLES BYROM RUSSEY MD (NPI 1437141041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437141041 NPI number — MR. CHARLES BYROM RUSSEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSEY
Provider First Name:
CHARLES
Provider Middle Name:
BYROM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1437141041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 W SOUTHLAKE BLVD
Provider Second Line Business Mailing Address:
STE 115
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-416-2221
Provider Business Mailing Address Fax Number:
817-424-5400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 W SOUTHLAKE BLVD
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-416-2221
Provider Business Practice Location Address Fax Number:
817-424-5400
Provider Enumeration Date:
08/19/2005

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: 207Q00000X , with the licence number:  K2373 , 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)





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