Provider Demographics
NPI:1710031265
Name:RUSSELL, BRIAN J (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
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 1:128 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2113
Mailing Address - Country:US
Mailing Address - Phone:630-941-3208
Mailing Address - Fax:
Practice Address - Street 1:128 E OAK ST
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2113
Practice Address - Country:US
Practice Address - Phone:630-941-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006311111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT90732Medicare UPIN
ILK14561Medicare ID - Type Unspecified