Healthcare Provider Details

I. General information

NPI: 1073937132
Provider Name (Legal Business Name): TIMOTHY GLENN RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8768
  • Fax:
Mailing address:
  • Phone: 270-798-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28048
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number28944
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: