Provider Demographics
NPI:1306814702
Name:RUSSO, MAUREEN T (PT)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:T
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S DUBUQUE ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-4266
Mailing Address - Country:US
Mailing Address - Phone:319-354-7511
Mailing Address - Fax:
Practice Address - Street 1:720 S DUBUQUE ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4266
Practice Address - Country:US
Practice Address - Phone:319-354-7511
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01505225100000X
CA10191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
27446Medicare ID - Type Unspecified