Basic Information
| Provider Information | |||||||||
| NPI: | 1053307223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 N ACCESS RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374153812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238261276 | ||||||||
| FaxNumber: | 4238261290 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313933000 | ||||||||
| FaxNumber: | 9313937806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD0000017613 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0093881 | 05 | TN | MEDICAID |