Provider Demographics
NPI:1427057736
Name:WILSON, RUSSELL ANDREW (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ANDREW
Last Name:WILSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:A
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1265 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 500B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4548
Mailing Address - Country:US
Mailing Address - Phone:770-719-5660
Mailing Address - Fax:678-817-4339
Practice Address - Street 1:1265 HIGHWAY 54 W STE 500B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4556
Practice Address - Country:US
Practice Address - Phone:770-719-5660
Practice Address - Fax:678-336-5955
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040590208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00711389CMedicaid
GAP00081030OtherRAILROAD MEDICARE
G28447Medicare UPIN
02BBGLSMedicare ID - Type Unspecified