Basic Information
| Provider Information | |||||||||
| NPI: | 1124254123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STURGEON | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 52 | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814020052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702528896 | ||||||||
| FaxNumber: | 9702403095 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 MERCHANT DR | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702528896 | ||||||||
| FaxNumber: | 9702403095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2009 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | DR0052648 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | DR0052648 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.