Provider Demographics
NPI:1689008658
Name:RUSSELL G. O'NEAL, M.D., L.L.C.
Entity Type:Organization
Organization Name:RUSSELL G. O'NEAL, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-309-1212
Mailing Address - Street 1:1760 BASS RD STE 200A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1061
Mailing Address - Country:US
Mailing Address - Phone:478-309-1212
Mailing Address - Fax:866-493-2791
Practice Address - Street 1:1760 BASS RD STE 200A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1061
Practice Address - Country:US
Practice Address - Phone:478-309-1212
Practice Address - Fax:866-493-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCDXCMedicare PIN