Healthcare Provider Details

I. General information

NPI: 1801213640
Provider Name (Legal Business Name): RUSSELL CHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

100 MADISON AVE
MORRISTOWN NJ
07960-6136
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-1000
  • Fax:
Mailing address:
  • Phone: 973-971-7926
  • Fax: 973-290-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number84279
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: