Individual
RUSSELL ANDREW WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1265 HIGHWAY 54 W STE 500B, FAYETTEVILLE, GA 30214-4556
(770) 719-5660
(678) 336-5955
Mailing address
1265 HIGHWAY 54 W, SUITE 500B, FAYETTEVILLE, GA 30214-4548
(770) 719-5660
(678) 817-4339
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
040590
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00711389C
—
GA
01
—
P00081030
RAILROAD MEDICARE
GA
Enumeration date
07/19/2005
Last updated
04/28/2025
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