Provider Demographics
NPI:1245336544
Name:BACH, RUSSELL WARREN (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WARREN
Last Name:BACH
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:PO BOX 3548
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78764-3548
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:1643 E 2ND ST BLDG C
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4411
Practice Address - Country:US
Practice Address - Phone:512-451-0315
Practice Address - Fax:512-804-3868
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH70432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF18417Medicare UPIN
TX81J967Medicare ID - Type Unspecified