Provider Demographics
NPI:1508870080
Name:RUSSEAU, KEVIN J (DC, DIBCN, DABFP)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:RUSSEAU
Suffix:
Gender:M
Credentials:DC, DIBCN, DABFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S NAPERVILLE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5473
Mailing Address - Country:US
Mailing Address - Phone:630-690-4040
Mailing Address - Fax:
Practice Address - Street 1:311 S NAPERVILLE RD
Practice Address - Street 2:SUITE C
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5473
Practice Address - Country:US
Practice Address - Phone:630-690-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007072111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
79863OtherHEALTH PARTNERS
4655917OtherAETNA
8228039001OtherCIGNA
IL022-22298OtherBC/BS
ILU34539Medicare UPIN
IL539590Medicare ID - Type Unspecified