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General NPI Number Information
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NPI Number | 1477651826
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Entity Type | Organization
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Legal Business Name | CHARLES B RUSSEY
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 480 W SOUTHLAKE BLVD SUITE 115
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City | SOUTHLAKE
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State | TX
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Zip | 76092
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Country | US
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Telephone | 817-416-2221
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Fax | 817-424-5400
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Provider Business Mailing Address
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Address Line | 480 W SOUTHLAKE BLVD SUITE 115
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City | SOUTHLAKE
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State | TX
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Zip | 76092
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Country | US
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Telephone | 817-416-2221
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Fax | 817-424-5400
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. HEATHER RENEE HARDIN
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Credential |
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Telephone | 814-162-2221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | K2373
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License Number State | TX
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