Provider Demographics
NPI:1841377553
Name:SMITH, RUSSELL GENE (PTA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:GENE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:322 SMITHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3645
Mailing Address - Country:US
Mailing Address - Phone:864-617-7538
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTHY WAY # 1110
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2067
Practice Address - Country:US
Practice Address - Phone:864-261-3099
Practice Address - Fax:864-261-6617
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC925225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant