Provider Demographics
NPI:1871629113
Name:SHERBONDY, RUSSELL MARK (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MARK
Last Name:SHERBONDY
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:W220S2041 SPRINGDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186
Mailing Address - Country:US
Mailing Address - Phone:414-769-7900
Mailing Address - Fax:
Practice Address - Street 1:1370 S 74TH ST
Practice Address - Street 2:STE 101
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3059
Practice Address - Country:US
Practice Address - Phone:414-769-7900
Practice Address - Fax:414-769-7953
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2391012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000070199Medicare ID - Type Unspecified