Provider Demographics
NPI:1558629881
Name:RUSSELL, CAITLIN R (DO)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-794-5550
Mailing Address - Fax:423-794-5867
Practice Address - Street 1:301 MED TECH PKWY STE 140
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2651
Practice Address - Country:US
Practice Address - Phone:423-794-5530
Practice Address - Fax:423-794-1824
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3070207Q00000X, 207Q00000X
SC37738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC377381Medicaid
SCSC76763365Medicare PIN
SC377381Medicaid
SCSC76766067Medicare PIN