1104081082 NPI number — DR. RUSSELL WILLIAM LAKE MD

Table of content: DR. RUSSELL WILLIAM LAKE MD (NPI 1104081082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104081082 NPI number — DR. RUSSELL WILLIAM LAKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKE
Provider First Name:
RUSSELL
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104081082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 E. 65TH STREET
Provider Second Line Business Mailing Address:
SUITE 22
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-7878
Provider Business Mailing Address Fax Number:
912-819-3320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10055 FORD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 3A
Provider Business Practice Location Address City Name:
RICHMOND HILL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-819-9601
Provider Business Practice Location Address Fax Number:
912-819-9605
Provider Enumeration Date:
07/21/2008

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: 207Q00000X , with the licence number:  31545 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 75198 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200480198D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003213522B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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