=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255893731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY RUSS DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 HARRY S TRUMAN DR N SUITE 140
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-527-7246
-----------------------------------------------------
Fax | 866-229-5063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 DEFENSE HWY STE 205
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-527-7246
-----------------------------------------------------
Fax | 866-229-5063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 20A21027
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 20A21027
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------