Healthcare Provider Details

I. General information

NPI: 1679505762
Provider Name (Legal Business Name): RUSSELL TREVENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 HUDSON BRIDGE RD
STOCKBRIDGE GA
30281-5020
US

IV. Provider business mailing address

1510 HUDSON BRIDGE RD
STOCKBRIDGE GA
30281-5020
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-8660
  • Fax: 404-785-8730
Mailing address:
  • Phone: 404-785-8660
  • Fax: 404-785-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number39251
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: