Provider Demographics
NPI:1265519094
Name:RUSSO, ROSEMARIE (DC)
Entity type:Individual
Prefix:DR
First Name:ROSEMARIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:ROSEMARIE
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOCTOR OF CHIRPRACTI
Mailing Address - Street 1:5301 SLATER MILL CIR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1203
Mailing Address - Country:US
Mailing Address - Phone:770-489-7704
Mailing Address - Fax:
Practice Address - Street 1:7193 DOUGLAS BLVD STE 101A
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1540
Practice Address - Country:US
Practice Address - Phone:770-942-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3319Medicare ID - Type Unspecified