MEDICARE: MR. JAMES MICHAEL RUSSELL D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	E3429	TX

General Provider Information

NPI Number	:	1689790636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES MICHAEL RUSSELL D.O.

Provider Business Mailing Address
First Line	:	6300 TROON RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4426
Country	:	US
Telephone Number	:	817-263-4977
Fax Number	:	817-292-0120

Provider Business Practice Location Address
First Line	:	6300 TROON RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4426
Country	:	US
Telephone Number	:	817-263-4977
Fax Number	:	817-292-0120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	12/26/2014

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