1780978338 NPI number — TELLY R RUSSELL MD

Table of content: TELLY R RUSSELL MD (NPI 1780978338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780978338 NPI number — TELLY R RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
TELLY
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1780978338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 LIND AVE SW
Provider Second Line Business Mailing Address:
SUITE 100 ATTN CREDENTIALING
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98057-4970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-690-2715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26458 MAPLE VALLEY BLACK DIAMOND RD SE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98038-8350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-690-3465
Provider Business Practice Location Address Fax Number:
425-690-9460
Provider Enumeration Date:
05/31/2011

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: 208M00000X , with the licence number:  MD60403590 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD60403590 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2020725 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8930107 . This is a "MEDICARE W VALLEY MEDICAL GROUP - RENTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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