Provider Demographics
NPI:1205038932
Name:RUSSELL, GEORGE (DC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
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 1:101 5TH AVE
Mailing Address - Street 2:SUITE 10C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1023
Mailing Address - Country:US
Mailing Address - Phone:646-654-9529
Mailing Address - Fax:212-488-2121
Practice Address - Street 1:101 5TH AVE
Practice Address - Street 2:SUITE 10C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1023
Practice Address - Country:US
Practice Address - Phone:646-654-9529
Practice Address - Fax:212-488-2121
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009793-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA562587529 0000OtherCIGNA HEALTHCARE INC.
CTP3695979OtherOHI INC. (OXFORD)
PA562587529 0000OtherCIGNA HEALTHCARE INC.