Provider Demographics
NPI:1124048889
Name:HERRINGTON, RUSSELL PRUITT SR (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PRUITT
Last Name:HERRINGTON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 SNOOPY LANE
Mailing Address - Street 2:
Mailing Address - City:PORTAL
Mailing Address - State:GA
Mailing Address - Zip Code:30450
Mailing Address - Country:US
Mailing Address - Phone:912-865-9353
Mailing Address - Fax:912-865-4175
Practice Address - Street 1:4800 48TH STREET
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3666
Practice Address - Country:US
Practice Address - Phone:334-756-9180
Practice Address - Fax:334-756-5874
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31261207P00000X
GA031261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00400815OtherRAILROAD MEDICARE
GA000400188EMedicaid
GA000400188HMedicaid
GA178575873AMedicaid
GA06BDHMHMedicare UPIN
GA000400188EMedicaid
GAP00400815OtherRAILROAD MEDICARE
GA000400188HMedicaid