Provider Demographics
NPI:1104850684
Name:RUSSELL, ROBERT ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 EAST BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552
Mailing Address - Country:US
Mailing Address - Phone:914-699-6770
Mailing Address - Fax:914-664-0090
Practice Address - Street 1:25 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552
Practice Address - Country:US
Practice Address - Phone:914-699-6770
Practice Address - Fax:914-664-0090
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2707C111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX14911Medicare ID - Type Unspecified