=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225617988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELINE RUSSELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2021
-----------------------------------------------------
Last Update Date | 06/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 JESSE HILL JR DR SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-616-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 WOODRUFF CIR NE STE 327
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-727-5658
-----------------------------------------------------
Fax | 404-727-3744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MT222711
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 17833
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------