Basic Information
Provider Information | |||||||||
NPI: | 1134367600 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOND | ||||||||
FirstName: | RUSSELL | ||||||||
MiddleName: | STOREY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 840853 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752840853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727155000 | ||||||||
FaxNumber: | 9727159976 | ||||||||
Practice Location | |||||||||
Address1: | 1500 CITYWEST BLVD | ||||||||
Address2: | STE. 300 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770422300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136204000 | ||||||||
FaxNumber: | 7134584229 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/21/2009 | ||||||||
LastUpdateDate: | 07/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 159090 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | APN 14177 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | AP120634 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | P00988004 | 01 | TX | RAILROAD MEDICARE | OTHER | 186288001 | 05 | AR |   | MEDICAID | P00750398 | 01 | TN | RAILROAD MEDICARE | OTHER | 08501017 | 05 | MS |   | MEDICAID | 1513757 | 05 | TN |   | MEDICAID | 287097401 | 05 | TX |   | MEDICAID | 287097402 | 05 | TX |   | MEDICAID | 4223159 | 01 | TN | BLUE CROSS | OTHER | 1134367600 | 01 | TN | CHAMPUS/HUMANA TRICARE | OTHER | 8130UC | 01 | TX | BCBS | OTHER |