Provider Demographics
NPI:1659362705
Name:RUSSELL PETTY, ERICKA M (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICKA
Middle Name:M
Last Name:RUSSELL PETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ERICKA
Other - Middle Name:M
Other - Last Name:RUSSELL-PETTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5710 OGEECHEE RD
Mailing Address - Street 2:STE 200 BOX 283
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-9515
Mailing Address - Country:US
Mailing Address - Phone:912-777-5490
Mailing Address - Fax:912-777-5491
Practice Address - Street 1:3710 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6209
Practice Address - Country:US
Practice Address - Phone:912-777-5490
Practice Address - Fax:912-777-5491
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000880448DMedicaid
GA000880448HMedicaid
GA000880448CMedicaid
GA000880448EMedicaid