Provider Demographics
NPI:1134115744
Name:RUSSELL, TRENT K (MD)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:K
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 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1057 MEDICAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-2745
Practice Address - Fax:573-348-8279
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107627208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208072900Medicaid
MO370013633OtherRAILROAD MEDICARE
MO004013557Medicare PIN
G13039Medicare UPIN