Basic Information
| Provider Information | |||||||||
| NPI: | 1497705800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980035947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259711866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 S STILLAGUAMISH AVE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982231642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604352133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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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 | 207PE0004X | MD00016164 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | MD00016164 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8151409 | 05 | WA | MEDICAID |