Provider Demographics
NPI:1407138381
Name:RUSSMANN, INC.
Entity Type:Organization
Organization Name:RUSSMANN, INC.
Other - Org Name:TENNESSEE MEDPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BODEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-414-2779
Mailing Address - Street 1:4163 BENNY DELOZIER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804
Mailing Address - Country:US
Mailing Address - Phone:865-379-9850
Mailing Address - Fax:
Practice Address - Street 1:4163 BENNY DELOZIER DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804
Practice Address - Country:US
Practice Address - Phone:865-379-9850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport