Provider Demographics
NPI:1659695807
Name:RUSSELL, ANDREW DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
Last Name:RUSSELL
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2481 LINCOLN HWY E
Practice Address - Street 2:SUITE 4
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-1482
Practice Address - Country:US
Practice Address - Phone:717-925-2100
Practice Address - Fax:717-390-1953
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA236909VKFMedicare PIN