Healthcare Provider Details

I. General information

NPI: 1770100026
Provider Name (Legal Business Name): PARKER TRENT RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-8000
  • Fax: 573-302-2297
Mailing address:
  • Phone: 573-348-8000
  • Fax: 573-302-2297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024027874
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024027874
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: