Provider Demographics
NPI:1669849485
Name:RUSSELL B SKINNER MD PA
Entity Type:Organization
Organization Name:RUSSELL B SKINNER MD PA
Other - Org Name:FAMILY HEALTH AND WELLNESS OF PLANO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-661-1100
Mailing Address - Street 1:5072 W PLANO PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4476
Mailing Address - Country:US
Mailing Address - Phone:469-661-1100
Mailing Address - Fax:469-661-1104
Practice Address - Street 1:5072 W PLANO PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4476
Practice Address - Country:US
Practice Address - Phone:469-661-1100
Practice Address - Fax:469-661-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG77583Medicare UPIN