Provider Demographics
NPI:1700876158
Name:RUSSELL, WILLIAM LEE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEE
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 1:120 FRANK MARTIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-7194
Mailing Address - Country:US
Mailing Address - Phone:931-685-0986
Mailing Address - Fax:931-685-0988
Practice Address - Street 1:120 FRANK MARTIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-7194
Practice Address - Country:US
Practice Address - Phone:931-685-0986
Practice Address - Fax:931-685-0988
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2014-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN97942086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B02836Medicare UPIN