Basic Information
| Provider Information | |||||||||
| NPI: | 1952424095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKISSICK | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9118 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554809118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153292294 | ||||||||
| FaxNumber: | 6156951494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 MEDICAL CENTER PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158966800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 41837 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 41837 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3000353 | 05 | TN | MEDICAID |