Provider Demographics
NPI:1952495863
Name:GREGORY, RUSSELL SCOTT (PTA)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:SCOTT
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 TOMCAT TRAIL
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-862-4027
Mailing Address - Fax:
Practice Address - Street 1:376 MANCHESTER SQUARE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-9998
Practice Address - Country:US
Practice Address - Phone:606-598-7673
Practice Address - Fax:606-598-7948
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist