Provider Demographics
NPI:1811974306
Name:BARTHOLOMEW, RUSS P (PT)
Entity type:Individual
Prefix:MR
First Name:RUSS
Middle Name:P
Last Name:BARTHOLOMEW
Suffix:
Gender:M
Credentials:PT
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:ADVANCED PHYSICAL THERAPY
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-991-2563
Practice Address - Street 1:2105 E ENTERPRISE AVE STE 113
Practice Address - Street 2:ADVANCED PHYSICAL THERAPY
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-991-2561
Practice Address - Fax:920-991-2563
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3978024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36116900Medicaid
001286443Medicare PIN
WI5567490001Medicare NSC