1326151812 NPI number — RUSSELL GROSS M D L L C

Table of content: KEITH BERGEN VAN ZANDT MD (NPI 1053373332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326151812 NPI number — RUSSELL GROSS M D L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELL GROSS M D L L C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1326151812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1995 HIGHWAY 51 S
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38019-3635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-476-9921
Provider Business Mailing Address Fax Number:
901-475-9272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1995 HIGHWAY 51 S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38019-3635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-476-9921
Provider Business Practice Location Address Fax Number:
901-475-9272
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
901-476-9921

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4112897 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4112897 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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