Provider Demographics
NPI:1649816430
Name:RUSS, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:FEARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:194 PIPE STAVE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2412
Mailing Address - Country:US
Mailing Address - Phone:631-338-5861
Mailing Address - Fax:
Practice Address - Street 1:1770 MOTOR PKWY STE 202
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5260
Practice Address - Country:US
Practice Address - Phone:631-582-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist