Basic Information
| Provider Information | |||||||||
| NPI: | 1679598718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1108 LAVACA ST | ||||||||
| Address2: | 110-320 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787012172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124774088 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1108 LAVACA ST | ||||||||
| Address2: | 110-320 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787012172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124774088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 05/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | F4461 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 097796902 | 05 | TX | MEDICAID | 110180474 | 01 | TX | MEDICARE RAILROAD | OTHER | 82020J | 01 | TX | BCBS TEXAS | OTHER |