Provider Demographics
NPI:1609297688
Name:FUNCHES, RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:FUNCHES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 E 73RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4827
Mailing Address - Country:US
Mailing Address - Phone:216-326-7487
Mailing Address - Fax:
Practice Address - Street 1:5908 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3012
Practice Address - Country:US
Practice Address - Phone:216-326-7487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT012482225100000X
OHPT 012482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist