Individual Professional Information |
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NPI
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1720076052
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Unique healthcare provider (clinician) ID assigned by NPPES
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PECOS UID
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0042244915
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Unique individual clinician ID assigned by PECOS
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Professional Enrollment ID
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I20100715000364
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Unique ID for the individual professional enrollment that is the source for the data in the observation
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Provider Last Name
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RUSSELL
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Individual professional last name
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Provider First Name
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MICHAEL
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Individual professional first name
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Provider Middle Name
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EDWARD
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Individual professional middle name
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Provider Name Suffix Text
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II
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The name suffix of the provider if the provider is an individual. The name suffix is a ''generation-related'' suffix, such as Jr., Sr., II, III, IV, or V.
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Provider Gender
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M
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The provider's gender if the provider is a person.
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Practice Information |
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Organization Legal Name
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AZALEA ORTHOPEDIC AND SPORTS MEDICINE CLINIC PA
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Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Group Practice PAC ID
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3274524467
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Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Number of Group Practice members
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41
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Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
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Line 1 Street Address
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305 W 20TH ST
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Group Practice or individual's line 1 address
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City
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MOUNT PLEASANT
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Group Practice or individual's city
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State
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TX
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Group Practice or individual's state
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Zip Code
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754552327
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Group Practice or individual's zip code (9 digits when available)
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Phone Number
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9035775661
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Phone number is listed only when there is a single phone number available for the practice location address
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Hospital(s) Affiliation Information |
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Hospital Affiliation CCN 1
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450864
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Medicare CCN of hospital where individual professional provides service 1
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Hospital Affiliation LBN 1
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BAYLOR SCOTT & WHITE TEXAS SPINE & JOINT HOSPITAL
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Legal business name of hospital where individual professional provides service 1
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Hospital Affiliation CCN 2
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450083
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Medicare CCN of hospital where individual professional provides service 2
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Hospital Affiliation LBN 2
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EAST TEXAS MEDICAL CENTER
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Legal business name of hospital where individual professional provides service 2
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Hospital Affiliation CCN 3
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450102
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Medicare CCN of hospital where individual professional provides service 3
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Hospital Affiliation LBN 3
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MOTHER FRANCES HOSPITAL
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Legal business name of hospital where individual professional provides service 3
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Hospital Affiliation CCN 4
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451367
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Medicare CCN of hospital where individual professional provides service 4
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Hospital Affiliation LBN 4
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EAST TEXAS MEDICAL CENTER PITTSBURG
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Legal business name of hospital where individual professional provides service 4
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Hospital Affiliation CCN 5
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450656
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Medicare CCN of hospital where individual professional provides service 5
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Hospital Affiliation LBN 5
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NACOGDOCHES MEDICAL CENTER
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Legal business name of hospital where individual professional provides service 5
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Professional Accepts Medicare Assignment
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Y
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