Provider Demographics
NPI:1679663686
Name:RUSSELL HARRIS, M.D., P.C.
Entity Type:Organization
Organization Name:RUSSELL HARRIS, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-851-9480
Mailing Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1786
Mailing Address - Country:US
Mailing Address - Phone:404-851-9480
Mailing Address - Fax:404-236-0075
Practice Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1786
Practice Address - Country:US
Practice Address - Phone:404-851-9480
Practice Address - Fax:404-236-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA215714OtherBLUE CROSS BLUE SHIELD
GA215714OtherBLUE CROSS BLUE SHIELD
GAGRP6827Medicare PIN