Provider Demographics
NPI:1194769257
Name:BROWN, RUSSELL E (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:BROWN
Suffix:
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 1:4688 TRINITY CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-1671
Mailing Address - Country:US
Mailing Address - Phone:404-316-4992
Mailing Address - Fax:770-973-3587
Practice Address - Street 1:4688 TRINITY CT
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-1671
Practice Address - Country:US
Practice Address - Phone:404-316-4992
Practice Address - Fax:770-973-3587
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0397432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00683867BMedicaid
GA13023578OtherRR MEDICARE
GA055003719AMedicaid
GA15-00149OtherEVERCARE
GA13023578OtherRR MEDICARE
GA13BDDJMMedicare ID - Type Unspecified