Individual
DR. TRENT K RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1057 MEDICAL PARK DR, SUITE A, OSAGE BEACH, MO 65065-3050
(573) 348-2745
(573) 348-8279
Mailing address
54 HOSPITAL DR, OSAGE BEACH, MO 65065-3050
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
107627
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
208072900
—
MO
01
—
370013633
RAILROAD MEDICARE
MO
Enumeration date
09/20/2005
Last updated
05/05/2008
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