MEDICARE: DR. JEFFERY A. RUSSELL DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR007961	GA

General Provider Information

NPI Number	:	1427122951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFERY A. RUSSELL DC

Provider Business Mailing Address
First Line	:	624 N MAIN AVE
Second Line	:	P.O. BOX 1690
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-2403
Country	:	US
Telephone Number	:	706-663-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 N MAIN AVE
Second Line	:
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-2403
Country	:	US
Telephone Number	:	706-663-8801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	07/26/2007

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