Provider Demographics
NPI:1962502880
Name:RUSSELL, MICHAEL A (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
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 1:18624 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3202
Mailing Address - Country:US
Mailing Address - Phone:216-221-1788
Mailing Address - Fax:216-221-2820
Practice Address - Street 1:18624 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3202
Practice Address - Country:US
Practice Address - Phone:216-221-1788
Practice Address - Fax:216-221-2820
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3307111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000232365OtherANTHEM
OH2321553Medicaid
OH2321553Medicaid
OHRU4097211Medicare ID - Type Unspecified