Provider Demographics
NPI:1669490298
Name:MCAFFEE, RUSS (ATC)
Entity Type:Individual
Prefix:MR
First Name:RUSS
Middle Name:
Last Name:MCAFFEE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3419
Mailing Address - Country:US
Mailing Address - Phone:208-681-5852
Mailing Address - Fax:
Practice Address - Street 1:275 S. 5TH AVE.
Practice Address - Street 2:STE. 140
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-1872081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine