Basic Information
| Provider Information | |||||||||
| NPI: | 1013046374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOCKER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1984 PEACHTREE RD NW | ||||||||
| Address2: | STE. 515 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303095219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511754 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 AIRPORT RD NW | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301447038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782022074 | ||||||||
| FaxNumber: | 6782900479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 003348 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.