Provider Demographics
NPI:1437192432
Name:RUSSAMANO, MICHAEL J (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:RUSSAMANO
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 1:1410 INCARNATION DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-5708
Mailing Address - Country:US
Mailing Address - Phone:434-817-7788
Mailing Address - Fax:
Practice Address - Street 1:1410 INCARNATION DR
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-5708
Practice Address - Country:US
Practice Address - Phone:434-817-7788
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X008T01Medicare ID - Type Unspecified
VAU83470Medicare UPIN