Provider Demographics
NPI:1639140833
Name:FRANK I RUSSO
Entity Type:Organization
Organization Name:FRANK I RUSSO
Other - Org Name:RUSSO REHABILITATION MEDICINE LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:CHIARAVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-689-6049
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-693-2244
Mailing Address - Fax:309-693-7606
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-693-2244
Practice Address - Fax:309-693-7606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212028Medicare ID - Type Unspecified