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NPI Code Detail

MEDICARE: JACK RUSSELLE LAKE D.O.

MEDICARE: JACK RUSSELLE LAKE D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician101304GA
22085R0202XDiagnostic Radiology Physician4205OK

General Provider Information

NPI Number : 1932248101
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK RUSSELLE LAKE D.O.
Provider Business Mailing Address
First Line : 700 E MOREHEAD ST STE 300
Second Line :
City : CHARLOTTE
State : NC
Zip : 28202-2742
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2624 DAWSON RD
Second Line :
City : ALBANY
State : GA
Zip : 31707-1609
Country : US
Telephone Number : 229-888-1624
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/05/2007
Last Update Date : 10/30/2024

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