Active NPI
Gregory Clinton Russell, O.D.
- Optometrist
- Kingsport, TN
National Provider Identifier
1033144225
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- ODT1813
- Practice address
- 102 Professional Park PVT Dr
Kingsport, TN 37663-2287 - Phone
- (423) 245-2222
- Fax
- (423) 245-4822
- NPI assigned
- Jul 12, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | ODT1813 | TN | Primary |
Addresses
Primary practice location
102 Professional Park PVT Dr
Kingsport, TN 37663-2287
Mailing address
102 Professional Park PVT Dr
Kingsport, TN 37663-2287
Phone (423) 245-2222
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3941713 | Medicaid | TN | |
| 4076931 | Other | TN | BLUE CROSS BLUE SHIELD OF |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040422001637 | TN | Practitioner - Optometry | 6103812235 | Practice locations: Kingsport, TN |
Care Compare profile
Medicare Care Compare- Specialty
- Optometry
- Education
- Southern College of Optometry, 1997
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
102 Professional Park Dr
Kingsport, TN 37663-2287
102 Professional Park PVT Dr
Kingsport, TN 37663-2287
Phone (423) 245-2222
Procedures performed for Medicare patients
| Procedure | Number of procedures |
|---|---|
| Cataract surgery | 93 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ODT1813 | TN | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152662400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1033144225",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "102 PROFESSIONAL PARK PVT DR",
"city": "KINGSPORT",
"state": "TN",
"postal_code": "376632287",
"telephone_number": "423-245-2222",
"fax_number": "423-245-4822"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "102 PROFESSIONAL PARK PVT DR",
"city": "KINGSPORT",
"state": "TN",
"postal_code": "376632287",
"telephone_number": "423-245-2222",
"fax_number": "423-245-4822"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSELL",
"first_name": "GREGORY",
"middle_name": "CLINTON",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-12",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "TN",
"license": "ODT1813",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3941713",
"state": "TN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD OF",
"identifier": "4076931",
"state": "TN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kingsport, TN
- Rural Health Services Consortium of Upper East Tennessee Inc
- Rural Health Services Consortium of Upper East Tennessee Inc (Kingsport Medical Center)
- Brittany Rushing, SLP
- Jeffrey Rushing, PHARMD
- Allison M Russell, MA
- Robert Rutherford, NP
- Stacey Ann Ryder, CRNA
- Kris B Saadeh, M.D.
- Sam Sadeghi, MD
- Pabitra K Saha, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.