Russell, Telly R

Russell, Telly R is an individual health care provider with primary practice located at 26458 Maple Valley Black Diamond Rd Se Ste A , Maple Valley WA 98038-8350. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Hospitalist, Allopathic & Osteopathic Physicians / Family Medicine. Allopathic & Osteopathic Physicians / Family Medicine is his primary health care specialty. Russell, Telly R can be contacted via phone (425) 690-3465.

Contact Information

Primary practice address
26458 Maple Valley Black Diamond Rd Se Ste A Maple Valley WA 98038-8350
Phone: (425) 690-3465
Fax: (425) 690-9460
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Hospitalist 208M00000X MD60403590 Washington
Allopathic & Osteopathic Physicians / Family Medicine 207Q00000X MD60403590 Washington

Profile Details

NPI number 1780978338
LBN Legal business name Russell, Telly R
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date May 31st, 2011
Last updated Mar 26th, 2020 - about 6 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1780978338 NPPES
Washington MEDICAID 2020725
Washington Other G8930107

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