Provider Demographics
NPI:1619948973
Name:RUSSO, MICHAEL S (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3054
Mailing Address - Country:US
Mailing Address - Phone:201-339-1109
Mailing Address - Fax:908-353-1505
Practice Address - Street 1:10 CHURCH TOWERS
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030
Practice Address - Country:US
Practice Address - Phone:201-401-9687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00991200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1619948973OtherNPI #
066750Medicare PIN
NJ1619948973OtherNPI #