Healthcare Provider Details

I. General information

NPI: 1356981898
Provider Name (Legal Business Name): MICHAEL RUSS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

IV. Provider business mailing address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-0374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: