MEDICARE: RUSSELL WILLIAM KRIDEL MD

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
1	207YS0123X	Facial Plastic Surgery Physician	E5815	TX

General Provider Information

NPI Number	:	1194889642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL WILLIAM KRIDEL MD

Provider Business Mailing Address
First Line	:	6655 TRAVIS ST STE 900
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1336
Country	:	US
Telephone Number	:	713-526-5665
Fax Number	:	713-526-5160

Provider Business Practice Location Address
First Line	:	6655 TRAVIS ST STE 900
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1336
Country	:	US
Telephone Number	:	713-526-5665
Fax Number	:	713-526-5160

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	05/13/2015

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