Provider Demographics
NPI:1740479526
Name:RUSSO, MICHAEL THOMAS (DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:15 COMMERCE RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4549
Mailing Address - Country:US
Mailing Address - Phone:203-324-9100
Mailing Address - Fax:203-324-9400
Practice Address - Street 1:15 COMMERCE RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4549
Practice Address - Country:US
Practice Address - Phone:203-324-9100
Practice Address - Fax:203-324-9400
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2014-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY029640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1740479526Medicare NSC