Provider Demographics
NPI:1104215441
Name:RUSSO, JOSEPH (PT, DPT, ATC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:486 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-3353
Practice Address - Country:US
Practice Address - Phone:224-783-6128
Practice Address - Fax:224-783-7737
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2024-02-08
Deactivation Date:2018-05-22
Deactivation Code:
Reactivation Date:2018-05-29
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070024137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist