Provider Demographics
NPI:1639563950
Name:RUSSO PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:RUSSO PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-507-3828
Mailing Address - Street 1:4266 ACME RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:NY
Mailing Address - Zip Code:13340-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4266 ACME RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:NY
Practice Address - Zip Code:13340-3504
Practice Address - Country:US
Practice Address - Phone:315-507-3828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0280701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty