Provider Demographics
NPI:1831732007
Name:PHILADELPHIA CONCUSSION SPECIALISTS
Entity type:Organization
Organization Name:PHILADELPHIA CONCUSSION SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:484-818-2225
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-0741
Mailing Address - Country:US
Mailing Address - Phone:484-818-2225
Mailing Address - Fax:866-818-4032
Practice Address - Street 1:3300 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1925
Practice Address - Country:US
Practice Address - Phone:484-818-2225
Practice Address - Fax:866-818-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-21
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty