MEDICARE: TIMOTHY RUSSELL R.T. (R)

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	247100000X	Radiologic Technologist	434864	TN

General Provider Information

NPI Number	:	1528471083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY RUSSELL R.T. (R)

Provider Business Mailing Address
First Line	:	6431 WADE SPRINGS RD
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-8719
Country	:	US
Telephone Number	:	615-522-1094
Fax Number	:	866-981-2872

Provider Business Practice Location Address
First Line	:	6431 WADE SPRINGS RD
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-8719
Country	:	US
Telephone Number	:	615-522-1094
Fax Number	:	866-981-2872

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

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	06/03/2014

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