Lake, Russell William
Lake, Russell William is an sole proprietor health care provider with primary practice located at 10055 Ford Avenue Suite 3A, Richmond Hill GA 31324. He recently has only one registered license in Allopathic & Osteopathic Physicians / Family Medicine, which is considered as his primary health care specialty. Lake, Russell William can be contacted via phone (912) 819-9601.Contact Information
Primary practice address
10055 Ford Avenue Suite 3A
Richmond Hill GA 31324
Phone: (912) 819-9601
Fax: (912) 819-9605
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Family Medicine | 207Q00000X | 31545 | South Carolina |
| Allopathic & Osteopathic Physicians / Family Medicine | 207Q00000X | 75198 | Georgia |
Profile Details
| NPI number | 1104081082 |
|---|---|
| LBN Legal business name | Lake, Russell William |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | Yes |
| Enumeration date | Jul 21st, 2008 |
| Last updated | Oct 19th, 2021 - about 3 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1104081082 | NPPES |
| Georgia | MEDICAID | 200480198D | |
| Georgia | MEDICAID | 003213522B |
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