1336134188 NPI number — MR. BRUCE LYNN RUSSELL M.D. PLLC

Table of content: MR. BRUCE LYNN RUSSELL M.D. PLLC (NPI 1336134188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336134188 NPI number — MR. BRUCE LYNN RUSSELL M.D. PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
BRUCE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D. PLLC
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:
1336134188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 CUT OFF ROAD
Provider Second Line Business Mailing Address:
SUITE 14
Provider Business Mailing Address City Name:
PORT ARANSAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78373-4246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-749-1930
Provider Business Mailing Address Fax Number:
361-749-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 CUT OFF RD
Provider Second Line Business Practice Location Address:
SUITE 14
Provider Business Practice Location Address City Name:
PORT ARANSAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78373-4245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-749-1930
Provider Business Practice Location Address Fax Number:
361-749-1933
Provider Enumeration Date:
09/19/2005

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:  187912 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: G8391 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1821670-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01276695 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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