Provider Demographics
NPI:1205990827
Name:RUSSELL, GYLES DONALD (PT)
Entity type:Individual
Prefix:MR
First Name:GYLES
Middle Name:DONALD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DARTMOUTH CIR
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7703
Mailing Address - Country:US
Mailing Address - Phone:865-483-6850
Mailing Address - Fax:865-483-7791
Practice Address - Street 1:800 OAK RIDGE TPKE
Practice Address - Street 2:SUITE C 102
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6957
Practice Address - Country:US
Practice Address - Phone:865-483-7790
Practice Address - Fax:865-483-7791
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT 157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist