Provider Demographics
NPI:1376643882
Name:GANNON, RUSSELL D (MSPT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:D
Last Name:GANNON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 TWIN BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35226-2342
Mailing Address - Country:US
Mailing Address - Phone:205-823-4236
Mailing Address - Fax:
Practice Address - Street 1:616 GADSDEN HWY
Practice Address - Street 2:SUITE A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-2501
Practice Address - Country:US
Practice Address - Phone:205-833-0881
Practice Address - Fax:205-833-1190
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH35022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-4518Medicare ID - Type Unspecified