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NPI Code Detail

MEDICARE: LARRY J RUSSELL

MEDICARE: LARRY J RUSSELL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1164495958
Entity Type Code : Organization
Provider Name (Legal Business Name) : LARRY J RUSSELL
Provider Business Mailing Address
First Line : 165 COOLRIDGE ST
Second Line :
City : HENDERSONVILLE
State : NC
Zip : 28792-2767
Country : US
Telephone Number : 828-694-3939
Fax Number : 828-692-0533
Provider Business Practice Location Address
First Line : 510 BALSAM RD
Second Line :
City : HENDERSONVILLE
State : NC
Zip : 28792-5703
Country : US
Telephone Number : 828-693-4431
Fax Number :
Authorized Official
Title or Position : PRACTICE MANAGER
Name : LAURA H WARD
Credential :
Telephone Number : 828-693-4431
Provider Enumeration Date : 02/10/2006
Last Update Date : 08/22/2020

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1053384859 — TST MEDICAL, P.A.
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