1124048889 NPI number — RUSSELL PRUITT HERRINGTON SR. M.D.

Table of content: JOHN BISTIS COTA/L (NPI 1952854317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124048889 NPI number — RUSSELL PRUITT HERRINGTON SR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERRINGTON
Provider First Name:
RUSSELL
Provider Middle Name:
PRUITT
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124048889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 SNOOPY LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-865-9353
Provider Business Mailing Address Fax Number:
912-865-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 48TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36854-3666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-756-9180
Provider Business Practice Location Address Fax Number:
334-756-5874
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  31261 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 031261 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00400815 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000400188E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000400188H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 178575873A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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