Healthcare Provider Details

I. General information

NPI: 1386795326
Provider Name (Legal Business Name): RUSSELL J BERSCHEID M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 TROTWOOD AVE
COLUMBIA TN
38401-6406
US

IV. Provider business mailing address

PO BOX 229
WAKEFIELD RI
02880-0229
US

V. Phone/Fax

Practice location:
  • Phone: 931-540-4140
  • Fax: 931-540-4143
Mailing address:
  • Phone: 401-788-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28088
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: