Provider Demographics
NPI:1497840219
Name:RUSSELL, BRYAN M (PT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3179
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:105 COLLIER RD NW
Practice Address - Street 2:SUITE 2000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1710
Practice Address - Country:US
Practice Address - Phone:404-352-1053
Practice Address - Fax:404-350-0840
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDKTMedicare ID - Type Unspecified