Provider Demographics
NPI:1205463486
Name:RUSSO, MICHAEL (PT, DPT, FAAOMPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT, DPT, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29800 BAINBRIDGE RD # SO40
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2202
Mailing Address - Country:US
Mailing Address - Phone:440-914-8603
Mailing Address - Fax:
Practice Address - Street 1:29800 BAINBRIDGE RD # SO40
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2202
Practice Address - Country:US
Practice Address - Phone:440-914-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0146622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH014662Other014662