Basic Information
| Provider Information | |||||||||
| NPI: | 1497840219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709536929 | ||||||||
| FaxNumber: | 7709536972 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 COLLIER RD NW | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043521053 | ||||||||
| FaxNumber: | 4043500840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008561 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.