Provider Demographics
NPI:1710907480
Name:RUSSELL, DERICK M (MPT)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CIRCLE AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2326
Mailing Address - Country:US
Mailing Address - Phone:708-691-3562
Mailing Address - Fax:708-660-9356
Practice Address - Street 1:6326 WEST ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304
Practice Address - Country:US
Practice Address - Phone:708-691-3562
Practice Address - Fax:708-660-9356
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic