Provider Demographics
NPI:1962427708
Name:KORT, RUSSELL J (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:KORT
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 1:20407 SW BORCHERS DR STE 201
Mailing Address - Street 2:
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:97140-8760
Practice Address - Country:US
Practice Address - Phone:503-625-5678
Practice Address - Fax:503-925-8302
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146472Medicare UPIN