Provider Demographics
NPI:1477651826
Name:CHARLES B RUSSEY
Entity Type:Organization
Organization Name:CHARLES B RUSSEY
Other - Org Name:ACUTE CARE AND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-162-2221
Mailing Address - Street 1:480 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
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:SUITE 115
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-416-2221
Practice Address - Fax:817-424-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8A1750Medicare ID - Type Unspecified
G76356Medicare UPIN