Healthcare Provider Details

I. General information

NPI: 1053873612
Provider Name (Legal Business Name): LONNIE NICHOLAS RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 CHEROKEE ST NE STE 100
MARIETTA GA
30060-8930
US

IV. Provider business mailing address

450 14TH ST NW
ATLANTA GA
30318-7963
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-8201
  • Fax:
Mailing address:
  • Phone: 843-291-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number88192
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: