Provider Demographics
NPI:1528424579
Name:PRIDGEN, RUSSELL L
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:L
Last Name:PRIDGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 KRISTIN LN
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-3247
Mailing Address - Country:US
Mailing Address - Phone:410-375-1996
Mailing Address - Fax:770-867-1651
Practice Address - Street 1:588 KRISTIN LN
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-3247
Practice Address - Country:US
Practice Address - Phone:410-375-1996
Practice Address - Fax:770-867-1651
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057447391171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1528424579Medicare UPIN