1790781706 NPI number — SCOTT ANTHONY RUSSELL MD

Table of content: SCOTT ANTHONY RUSSELL MD (NPI 1790781706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790781706 NPI number — SCOTT ANTHONY RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
SCOTT
Provider Middle Name:
ANTHONY
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:
1790781706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7200 WYOMING SPGS
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78681-4307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-244-0111
Provider Business Mailing Address Fax Number:
512-244-2479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 S AUSTIN AVE
Provider Second Line Business Practice Location Address:
STE 330
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78626-7545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-864-3183
Provider Business Practice Location Address Fax Number:
512-930-3409
Provider Enumeration Date:
06/23/2005

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: 208600000X , with the licence number:  H4662 , 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: 117275102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4232187 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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