Provider Demographics
NPI:1194125161
Name:RUSSELL PERRY, MD, PA
Entity type:Organization
Organization Name:RUSSELL PERRY, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:GUILBEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-892-7090
Mailing Address - Street 1:205 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-2213
Mailing Address - Country:US
Mailing Address - Phone:409-892-7090
Mailing Address - Fax:409-892-4324
Practice Address - Street 1:205 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-2213
Practice Address - Country:US
Practice Address - Phone:409-892-7090
Practice Address - Fax:409-892-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX346314301Medicaid