Provider Demographics
NPI:1336134188
Name:RUSSELL, BRUCE LYNN (MD PLLC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CUT OFF ROAD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373-4246
Mailing Address - Country:US
Mailing Address - Phone:361-749-1930
Mailing Address - Fax:361-749-1933
Practice Address - Street 1:600 CUT OFF RD
Practice Address - Street 2:SUITE 14
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-4245
Practice Address - Country:US
Practice Address - Phone:361-749-1930
Practice Address - Fax:361-749-1933
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8391207P00000X
NY187912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01276695Medicaid
TX1821670-01Medicaid
NYCC1968Medicare ID - Type Unspecified
TX1821670-01Medicaid