Provider Demographics
NPI:1093714222
Name:RUSSELL, KERRY BRUCE (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:BRUCE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 HANNAH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3110
Mailing Address - Country:US
Mailing Address - Phone:231-947-2228
Mailing Address - Fax:231-947-2616
Practice Address - Street 1:692 HANNAH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3110
Practice Address - Country:US
Practice Address - Phone:231-947-2228
Practice Address - Fax:231-947-2616
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-09-09
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MIKR007665111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4417133Medicaid
MIP99464OtherBLUE CARE NETWORK
MIU72489OtherPRIORITY HEALTH
MI611406599OtherPPOM
MI15934OtherMCARE
MI950B850440OtherBCBSM PPO
MI15934OtherMCARE
MI4417133Medicaid