1558366781 NPI number — DR. BRYAN C RUSSELL DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558366781 NPI number — DR. BRYAN C RUSSELL DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
BRYAN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558366781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
04/07/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
651 ROUTE 73 N STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-3446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-983-4499
Provider Business Mailing Address Fax Number:
856-983-0435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
651 ROUTE 73 N STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-983-4499
Provider Business Practice Location Address Fax Number:
856-983-0435
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  MC04977 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5716020 . This is a "MULTIPLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1874679 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5257680 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 662068 . This is a "ACN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0741915000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2039337 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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