Provider Demographics
NPI:1417056821
Name:RUSS, BRIAN SCOTT (PT COMT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SCOTT
Last Name:RUSS
Suffix:
Gender:M
Credentials:PT COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:SUITE A-11
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:6169 S JOG RD STE A11
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6586
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-1075
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL827472OtherGHI
FL891440100Medicaid
FL10769816OtherCAQH
FLU4319ZMedicare ID - Type Unspecified