Provider Demographics
NPI:1841287521
Name:RUSSELL H. PATTERSON III, MD
Entity type:Organization
Organization Name:RUSSELL H. PATTERSON III, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:901-382-1200
Mailing Address - Street 1:PO BOX 2121
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38159-0001
Mailing Address - Country:US
Mailing Address - Phone:901-382-1200
Mailing Address - Fax:901-382-8070
Practice Address - Street 1:6215 HUMPHREYS BLVD
Practice Address - Street 2:SUITE 505
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2367
Practice Address - Country:US
Practice Address - Phone:901-382-1200
Practice Address - Fax:901-382-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000006686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4036248OtherBLUE SHIELD TN
TN4036248OtherBLUE SHIELD TN
B00963Medicare UPIN