Provider Demographics
NPI:1972016210
Name:RUSSELL DENEA, MD, LLC
Entity Type:Organization
Organization Name:RUSSELL DENEA, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-471-1300
Mailing Address - Street 1:4102 A1A S
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6942
Mailing Address - Country:US
Mailing Address - Phone:904-471-1300
Mailing Address - Fax:904-471-1333
Practice Address - Street 1:4102 A1A S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6942
Practice Address - Country:US
Practice Address - Phone:904-471-1300
Practice Address - Fax:904-471-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty