Provider Demographics
NPI:1851323810
Name:TYNES, RUSSELL WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:TYNES
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 1:460 ASHLEY RIDGE BLVD
Mailing Address - Street 2:500
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7228
Mailing Address - Country:US
Mailing Address - Phone:318-212-1610
Mailing Address - Fax:866-455-7515
Practice Address - Street 1:460 ASHLEY RIDGE BLVD
Practice Address - Street 2:500
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7228
Practice Address - Country:US
Practice Address - Phone:318-212-1610
Practice Address - Fax:866-455-7515
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351661Medicaid
B61615Medicare UPIN
LA5M069Medicare PIN