Provider Demographics
NPI:1992886667
Name:PRUITT, RUSSELL FRANKLIN (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:FRANKLIN
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4900 IVEY RD NW BLDG 1000
Mailing Address - Street 2:SUITE 1025
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4001
Mailing Address - Country:US
Mailing Address - Phone:770-917-9557
Mailing Address - Fax:770-917-9558
Practice Address - Street 1:4900 IVEY RD NW BLDG 1000
Practice Address - Street 2:SUITE 1025
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4001
Practice Address - Country:US
Practice Address - Phone:770-917-9557
Practice Address - Fax:770-917-9558
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041931174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG26916Medicare UPIN
GA02BDJGXMedicare PIN