Provider Demographics
NPI:1003861667
Name:BURLINGAME, RUSSELL (PT, MS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:BURLINGAME
Suffix:
Gender:M
Credentials:PT, MS
Other - Prefix:
Other - First Name:RUSTY
Other - Middle Name:
Other - Last Name:BURLINGAME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, MS
Mailing Address - Street 1:401 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7108
Mailing Address - Country:US
Mailing Address - Phone:907-357-2578
Mailing Address - Fax:
Practice Address - Street 1:401 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7108
Practice Address - Country:US
Practice Address - Phone:907-357-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1175225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT 1175Medicaid
AKK152099Medicare ID - Type UnspecifiedMEDICARE #