Healthcare Provider Details

I. General information

NPI: 1750356382
Provider Name (Legal Business Name): PATRICK TODD RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON
TYLER TX
75701
US

IV. Provider business mailing address

PO BOX 5500
TYLER TX
75712-5500
US

V. Phone/Fax

Practice location:
  • Phone: 903-510-1186
  • Fax: 903-525-1254
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK6781
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: