Provider Demographics
NPI:1891970257
Name:RUSSELL J KORT DC PC
Entity type:Organization
Organization Name:RUSSELL J KORT DC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-625-5678
Mailing Address - Street 1:20407 SW BORCHERS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8988
Mailing Address - Country:US
Mailing Address - Phone:503-625-5678
Mailing Address - Fax:503-925-8302
Practice Address - Street 1:20407 SW BORCHERS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8988
Practice Address - Country:US
Practice Address - Phone:503-625-5678
Practice Address - Fax:503-925-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 3147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146471Medicare UPIN