| Doctor Name: | DR. TIMOTHY GLENN RUSSELL |
| NPI Number: | 1073937132 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 28944 |
| Business Practice Address: | 3551 Roger Brooke Dr Saushec Diagnostic Radiology Residency Jbsa Ft Sam Houston, TX - 782344504 |
| Business Phone Number: | 2109163290 |
| Business Fax Number: | 2109169256 |
| Mailing Address: | 3551 Roger Brooke, Saushec Diagnostic Radiology Residency JBSA FORT SAM HOUSTON |
| State: | TX |
| Postal Code: | 78234 |
| Phone Number: | 2109165545 |
| Fax Number: | 2109169256 |
| NPI Enumeration Date: | 02/10/2014 |
| NPI Last Update Date: | 01/11/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 28944 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NE |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |