Provider Demographics
NPI:1417387663
Name:RUSSO, ROBERTO
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:
Practice Address - Street 1:1919 SKOKIE VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2361
Practice Address - Country:US
Practice Address - Phone:224-765-5550
Practice Address - Fax:224-765-5551
Is Sole Proprietor?:No
Enumeration Date:2013-11-24
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006663225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant