Provider Demographics
NPI:1639243462
Name:DI RUSSA, BRIAN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:DI RUSSA
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 1:80 MARYS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5614
Mailing Address - Country:US
Mailing Address - Phone:631-283-7474
Mailing Address - Fax:631-283-7423
Practice Address - Street 1:80 MARYS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5614
Practice Address - Country:US
Practice Address - Phone:631-283-7474
Practice Address - Fax:631-283-7423
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007686-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5803948OtherGHI PROVIDER NUMBER
NY75723OtherVYTRA HIP PROVIDER NUMBER
NYCO 7686-1OtherWORKERS COMPENSATION
NYCO 7686-1OtherWORKERS COMPENSATION