MEDICARE: DR. KEITH WAYNE RUSSELL D O

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	2084P0800X	Psychiatry Physician	19746	OK

General Provider Information

NPI Number	:	1730270018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH WAYNE RUSSELL D O

Provider Business Mailing Address
First Line	:	1200 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73152-3277
Country	:	US
Telephone Number	:	405-522-2368
Fax Number	:	405-522-4120

Provider Business Practice Location Address
First Line	:	1200 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73152-3277
Country	:	US
Telephone Number	:	405-522-2368
Fax Number	:	405-522-4120

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/08/2007

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