Provider Demographics
NPI:1437141041
Name:RUSSEY, CHARLES BYROM (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BYROM
Last Name:RUSSEY
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 1:480 W SOUTHLAKE BLVD
Mailing Address - Street 2:STE 115
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6162
Mailing Address - Country:US
Mailing Address - Phone:817-416-2221
Mailing Address - Fax:817-424-5400
Practice Address - Street 1:480 W SOUTHLAKE BLVD
Practice Address - Street 2:STE 115
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6162
Practice Address - Country:US
Practice Address - Phone:817-416-2221
Practice Address - Fax:817-424-5400
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A1750Medicare ID - Type Unspecified
G76536Medicare UPIN