Provider Demographics
NPI:1831589969
Name:RUSSO, KARL JOSEPH (PTA)
Entity type:Individual
Prefix:MR
First Name:KARL
Middle Name:JOSEPH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENOLDEN
Mailing Address - State:PA
Mailing Address - Zip Code:19036-1101
Mailing Address - Country:US
Mailing Address - Phone:610-461-6522
Mailing Address - Fax:
Practice Address - Street 1:901 W ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GLENOLDEN
Practice Address - State:PA
Practice Address - Zip Code:19036-1101
Practice Address - Country:US
Practice Address - Phone:610-461-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE007568225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant