Provider Demographics
NPI:1174642631
Name:GLASSMAN, RUSSELL JON (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JON
Last Name:GLASSMAN
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 1:3509 BRASELTON HWY
Mailing Address - Street 2:BUILDING F
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1027
Mailing Address - Country:US
Mailing Address - Phone:770-614-6630
Mailing Address - Fax:770-614-6684
Practice Address - Street 1:3509 BRASELTON HWY
Practice Address - Street 2:BUILDING F
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1027
Practice Address - Country:US
Practice Address - Phone:770-614-6630
Practice Address - Fax:770-614-6684
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJJNMedicare ID - Type Unspecified