Basic Information
| Provider Information | |||||||||
| NPI: | 1124048889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRINGTON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | PRUITT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 SNOOPY LANE | ||||||||
| Address2: | |||||||||
| City: | PORTAL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128659353 | ||||||||
| FaxNumber: | 9128654175 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 48TH STREET | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368543666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347569180 | ||||||||
| FaxNumber: | 3347565874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 31261 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 031261 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00400815 | 01 | GA | RAILROAD MEDICARE | OTHER | 000400188E | 05 | GA | MEDICAID | 000400188H | 05 | GA | MEDICAID | 178575873A | 05 | GA | MEDICAID |