Healthcare Provider Details

I. General information

NPI: 1003800665
Provider Name (Legal Business Name): RUSSELL GORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WOODRUFF CIR STE 6000
ATLANTA GA
30322-0001
US

IV. Provider business mailing address

2020 PEACHTREE RD NW
ATLANTA GA
30309-1426
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-5004
  • Fax:
Mailing address:
  • Phone: 404-350-7323
  • Fax: 404-350-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number052072
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number52072
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: