Provider Demographics
NPI:1992206577
Name:RUSSO, TIMOTHY MORGAN (CPO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MORGAN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1S376 SUMMIT AVE
Mailing Address - Street 2:CT. E
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3985
Mailing Address - Country:US
Mailing Address - Phone:630-705-4092
Mailing Address - Fax:630-424-0467
Practice Address - Street 1:401 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1427
Practice Address - Country:US
Practice Address - Phone:708-383-2257
Practice Address - Fax:708-383-0739
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213.000337222Z00000X
IL211.000298224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist