Provider Demographics
NPI:1629356746
Name:STINCHCOMB, RUSSELL R (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:R
Last Name:STINCHCOMB
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 1:4425 PAULSEN ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-3663
Mailing Address - Country:US
Mailing Address - Phone:912-525-1279
Mailing Address - Fax:912-354-5973
Practice Address - Street 1:4425 PAULSEN ST BLDG A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-3663
Practice Address - Country:US
Practice Address - Phone:912-525-1279
Practice Address - Fax:912-354-5973
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20265I2526Medicare PIN