Provider Demographics
NPI:1275070641
Name:RUSSALIAH, MANOJABASINGH
Entity Type:Individual
Prefix:
First Name:MANOJABASINGH
Middle Name:
Last Name:RUSSALIAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MANO JABA SINGH
Other - Middle Name:
Other - Last Name:RUSSALIAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NYS PT
Mailing Address - Street 1:4332 KISSENA BLVD
Mailing Address - Street 2:1T
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2934
Mailing Address - Country:US
Mailing Address - Phone:518-364-2954
Mailing Address - Fax:
Practice Address - Street 1:8003 211TH ST
Practice Address - Street 2:HOLLIS HILLS
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1012
Practice Address - Country:US
Practice Address - Phone:518-364-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038995225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist