=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700854825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN S RUSSELL DPM FACFAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 10/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 WHITCHER ST STE. 450
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-590-4188
-----------------------------------------------------
Fax | 770-590-4189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 559 VINCENT ST ATTN: 21 MDOS/SGOF - ORTHO
-----------------------------------------------------
City | PETERSON AFB
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80914-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-526-2273
-----------------------------------------------------
Fax | 877-813-1756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | POD001261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | POD001261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------