Provider Demographics
NPI:1235158601
Name:RUSS, MICHAEL LOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOYD
Last Name:RUSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HEMPSTEAD AVE
Mailing Address - Street 2:SUITE 258
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4033
Mailing Address - Country:US
Mailing Address - Phone:516-536-3800
Mailing Address - Fax:
Practice Address - Street 1:5441 N UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4640
Practice Address - Country:US
Practice Address - Phone:954-803-9002
Practice Address - Fax:954-933-2305
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188435208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY09J401Medicare ID - Type Unspecified
NYF79008Medicare UPIN