Provider Demographics
NPI:1578500211
Name:HOLLANDER, RUSSELL (OT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HOLLANDER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 N WINCHESTER AVE
Mailing Address - Street 2:3RD FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-250-0500
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:3RD FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-250-0500
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056000818225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28148Medicare PIN
ILK28149Medicare PIN