Provider Demographics
NPI:1720021231
Name:RUSSELL, HUBERT WILLIAM JR (DC)
Entity Type:Individual
Prefix:DR
First Name:HUBERT
Middle Name:WILLIAM
Last Name:RUSSELL
Suffix:JR
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 1:15195 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2921
Mailing Address - Country:US
Mailing Address - Phone:734-284-9800
Mailing Address - Fax:734-284-9088
Practice Address - Street 1:15195 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2921
Practice Address - Country:US
Practice Address - Phone:734-284-9800
Practice Address - Fax:734-284-9088
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHR004208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOQ25014OtherOLD BCBS #
MI2906559Medicaid
MI95OH227870OtherNEW GRP # AS OF 7-18-06
MI95OH227880OtherDR RUSSELL'S INDIVDUAL #
MI95OH227870OtherNEW GRP # AS OF 7-18-06
MIOH225530Medicare ID - Type Unspecified