Provider Demographics
NPI:1043200603
Name:RUSSELL, GERALD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:THOMAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:11130 KINGSTON PIKE
Practice Address - Street 2:SUITE 7&8
Practice Address - City:FARRAGUT
Practice Address - State:TN
Practice Address - Zip Code:37934-2865
Practice Address - Country:US
Practice Address - Phone:865-675-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31906521Medicaid
TN3706633OtherMEDICARE GROUP
TN3706633OtherMEDICAID GROUP
B04434Medicare UPIN
TN31906521Medicare PIN