Provider Demographics
NPI:1427117415
Name:ROSELLE, RUSSELL THOMAS (CHIROPRACTOR DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:THOMAS
Last Name:ROSELLE
Suffix:
Gender:M
Credentials:CHIROPRACTOR DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8500 EXECUTIVE PARK AVENUE
Mailing Address - Street 2:#300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4642
Mailing Address - Country:US
Mailing Address - Phone:703-698-7117
Mailing Address - Fax:703-698-5729
Practice Address - Street 1:8500 EXECUTIVE PARK AVENUE
Practice Address - Street 2:#300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4647
Practice Address - Country:US
Practice Address - Phone:703-698-7117
Practice Address - Fax:703-698-5729
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000223111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA475913Medicare ID - Type UnspecifiedGROUP
VA024161R13Medicare ID - Type Unspecified