Provider Demographics
NPI:1457521619
Name:RUSSELL W FARIA DO PC
Entity Type:Organization
Organization Name:RUSSELL W FARIA DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKAUSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-293-9966
Mailing Address - Street 1:15215 SE 272ND ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4215
Mailing Address - Country:US
Mailing Address - Phone:253-639-1883
Mailing Address - Fax:253-639-1891
Practice Address - Street 1:15215 SE 272ND ST STE 103
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-4215
Practice Address - Country:US
Practice Address - Phone:253-639-1883
Practice Address - Fax:253-639-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD020354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150278Medicaid
ORD020354OtherLICENSE NUMBER
ORC39126Medicare UPIN