Provider Demographics
NPI:1780978338
Name:RUSSELL, TELLY R (MD)
Entity type:Individual
Prefix:
First Name:TELLY
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE STE A
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8350
Practice Address - Country:US
Practice Address - Phone:425-690-3465
Practice Address - Fax:425-690-9460
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60403590208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020725Medicaid
WAG8930107OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON