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General NPI Number Information
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NPI Number | 1053873612
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Entity Type | Individual
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Provider Name | LONNIE NICHOLAS RUSSELL MD
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Gender | Male
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Dates
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Enumeration Date | 04/03/2019
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Last Update Date | 09/27/2023
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Provider Practice Location Address
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Address Line | 660 CHEROKEE ST NE STE 100
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City | MARIETTA
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State | GA
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Zip | 30060-8930
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Country | US
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Telephone | 678-797-8201
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Fax |
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Provider Business Mailing Address
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Address Line | 450 14TH ST NW
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City | ATLANTA
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State | GA
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Zip | 30318-7963
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Country | US
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Telephone | 843-291-2836
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 88192
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License Number State | GA
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