MEDICARE: RUSSELL DENEA, MD, LLC

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	102L00000X	Psychoanalyst
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1972016210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL DENEA, MD, LLC

Provider Business Mailing Address
First Line	:	4102 A1A S
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6942
Country	:	US
Telephone Number	:	904-471-1300
Fax Number	:	904-471-1333

Provider Business Practice Location Address
First Line	:	4102 A1A S
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6942
Country	:	US
Telephone Number	:	904-471-1300
Fax Number	:	904-471-1333

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUSSELL DENEA
Credential	:	MD
Telephone Number	:	904-471-1300

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	12/27/2017

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