Provider Demographics
NPI:1801097944
Name:MARYANN RUSSO, PT
Entity type:Organization
Organization Name:MARYANN RUSSO, PT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:914-962-2728
Mailing Address - Street 1:3535 HILL BLVD
Mailing Address - Street 2:SUITE P
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-1293
Mailing Address - Country:US
Mailing Address - Phone:914-962-2728
Mailing Address - Fax:914-962-1729
Practice Address - Street 1:3535 HILL BLVD
Practice Address - Street 2:SUITE P
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-1293
Practice Address - Country:US
Practice Address - Phone:914-962-2728
Practice Address - Fax:914-962-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ53312Medicare ID - Type Unspecified