Provider Demographics
NPI:1790781706
Name:RUSSELL, SCOTT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANTHONY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7200 WYOMING SPGS
Mailing Address - Street 2:STE 500
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4307
Mailing Address - Country:US
Mailing Address - Phone:512-244-0111
Mailing Address - Fax:512-244-2479
Practice Address - Street 1:3201 S AUSTIN AVE
Practice Address - Street 2:STE 330
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7545
Practice Address - Country:US
Practice Address - Phone:512-864-3183
Practice Address - Fax:512-930-3409
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH4662208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117275102Medicaid
TX4232187OtherAETNA
TX020024556Medicare PIN
TX81A069Medicare PIN
TX117275102Medicaid