Healthcare Provider Details

I. General information

NPI: 1497840219
Provider Name (Legal Business Name): BRYAN M RUSSELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COLLIER RD NW SUITE 2000
ATLANTA GA
30309-1710
US

IV. Provider business mailing address

100 GALLERIA PKWY SE SUITE 410
ATLANTA GA
30339-3179
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-1053
  • Fax: 404-350-0840
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number008561
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: