Provider Demographics
NPI:1558366781
Name:RUSSELL, BRYAN C (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
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 1:651 ROUTE 73 N STE 304
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3446
Mailing Address - Country:US
Mailing Address - Phone:856-983-4499
Mailing Address - Fax:856-983-0435
Practice Address - Street 1:651 ROUTE 73 N STE 304
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3446
Practice Address - Country:US
Practice Address - Phone:856-983-4499
Practice Address - Fax:856-983-0435
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2023-12-28
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
NJMC04977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5716020OtherMULTIPLAN
NJ1874679OtherUNITED HEALTHCARE
NJ5257680OtherAETNA
NJ662068OtherACN
NJ0741915000OtherAMERIHEALTH
NJP2039337OtherOXFORD
NJ0741915000OtherAMERIHEALTH
NJ5257680OtherAETNA