Provider Demographics
NPI:1003458027
Name:RUSSELL, RODNEY GORDON JR (PT, DPT, CERT DN)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:GORDON
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:PT, DPT, CERT DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 B NORWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2412
Mailing Address - Country:US
Mailing Address - Phone:606-872-1601
Mailing Address - Fax:606-678-0333
Practice Address - Street 1:438 B NORWOOD RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2412
Practice Address - Country:US
Practice Address - Phone:606-872-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist