Provider Demographics
NPI:1215946389
Name:RUSSO, IGOR (DC)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-2753
Mailing Address - Country:US
Mailing Address - Phone:708-763-9622
Mailing Address - Fax:773-863-7675
Practice Address - Street 1:6931 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1053
Practice Address - Country:US
Practice Address - Phone:708-763-0580
Practice Address - Fax:708-763-0586
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor