Provider Demographics
NPI:1700854825
Name:RUSSELL, BRYAN S (DPM FACFAS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPM FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:ATTN: 21 MDOS/SGOF - ORTHO
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-526-2273
Mailing Address - Fax:877-813-1756
Practice Address - Street 1:55 WHITCHER ST
Practice Address - Street 2:STE. 450
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-590-4188
Practice Address - Fax:770-590-4189
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001261213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003150721CMedicaid
GA202I489193Medicare PIN
GAU95523Medicare UPIN