Provider Demographics
NPI:1457370223
Name:RUSSELL, JILL ANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ANNETTE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 MCGINNIS FERRY RD
Mailing Address - Street 2:SUITE # 108
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1633
Mailing Address - Country:US
Mailing Address - Phone:770-622-9446
Mailing Address - Fax:770-622-9440
Practice Address - Street 1:7810 MCGINNIS FERRY RD
Practice Address - Street 2:SUITE #108
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1633
Practice Address - Country:US
Practice Address - Phone:770-622-9446
Practice Address - Fax:770-622-9440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G15114Medicare UPIN