Basic Information
| Provider Information | |||||||||
| NPI: | 1730123142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNIGHT | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 CHERRY BARK DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390479519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667543852 | ||||||||
| FaxNumber: | 2053135245 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 S GLOSTER ST | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667543852 | ||||||||
| FaxNumber: | 2053135245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 18957 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | BK9378109 | 01 | MS | DEA # | OTHER |