Provider Demographics
NPI:1578771705
Name:TONG, RUSSELL DORRANCE (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DORRANCE
Last Name:TONG
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 1:9913 W STATE ROUTE 163
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-1532
Mailing Address - Country:US
Mailing Address - Phone:419-898-2029
Mailing Address - Fax:419-898-1689
Practice Address - Street 1:9913 W STATE ROUTE 163
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-1532
Practice Address - Country:US
Practice Address - Phone:419-898-2029
Practice Address - Fax:419-898-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH950111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0508178Medicaid
OHTO-0519792Medicare ID - Type Unspecified
OHT47657Medicare UPIN