MEDICARE: LORI RUSSELL P.A.

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	363AM0700X	Medical Physician Assistant	1198	TN

General Provider Information

NPI Number	:	1891798377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI RUSSELL P.A.

Provider Business Mailing Address
First Line	:	100 HUNTERS LN
Second Line	:	SUITE 100
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-8263
Country	:	US
Telephone Number	:	931-455-4616
Fax Number	:	931-455-2362

Provider Business Practice Location Address
First Line	:	100 HUNTERS LN
Second Line	:	SUITE 100
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-8263
Country	:	US
Telephone Number	:	931-455-4616
Fax Number	:	931-455-2362

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/06/2012

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