MEDICARE: DR. RUSSELL CHAMBLESS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT001097	GA

General Provider Information

NPI Number	:	1396968566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL CHAMBLESS OD

Provider Business Mailing Address
First Line	:	3353 MERCER UNIVERSITY DRIVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204
Country	:	US
Telephone Number	:	478-745-1515
Fax Number	:

Provider Business Practice Location Address
First Line	:	3353 MERCER UNIVERSITY DR
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-5082
Country	:	US
Telephone Number	:	478-745-1515
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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