Provider Demographics
NPI:1396834271
Name:RUSSELL, BRIAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3445 BANNERMAN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-7053
Mailing Address - Country:US
Mailing Address - Phone:850-999-4894
Mailing Address - Fax:850-668-0572
Practice Address - Street 1:100 MIMOSA DR STE 110
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6676
Practice Address - Country:US
Practice Address - Phone:850-999-4894
Practice Address - Fax:850-668-0572
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131234207T00000X
IL036-078323207T00000X
GA076453207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078323Medicaid