Provider Demographics
NPI:1679575997
Name:RUSSELL, WENDY KIAH (MD)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:KIAH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:K
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3999 AUSTELL RD SUITE 901
Mailing Address - Street 2:WELLSTREET URGENT CARE
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:770-809-3032
Mailing Address - Fax:678-817-4058
Practice Address - Street 1:3999 AUSTELL RD SUITE 901
Practice Address - Street 2:WELLSTREET URGENT CARE
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-809-3032
Practice Address - Fax:678-817-4058
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45442207Q00000X
GA045442207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00836085HMedicaid
GA08BBVJKMedicare ID - Type Unspecified
GA00836085HMedicaid