Basic Information
| Provider Information | |||||||||
| NPI: | 1679575997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | KIAH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3999 AUSTELL RD SUITE 901 | ||||||||
| Address2: | WELLSTREET URGENT CARE | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093032 | ||||||||
| FaxNumber: | 6788174058 | ||||||||
| Practice Location | |||||||||
| Address1: | 3999 AUSTELL RD SUITE 901 | ||||||||
| Address2: | WELLSTREET URGENT CARE | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093032 | ||||||||
| FaxNumber: | 6788174058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45442 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 045442 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00836085H | 05 | GA | MEDICAID |