MEDICARE: JEFF RUSS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05009096A	IN

General Provider Information

NPI Number	:	1023627023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFF RUSS PT

Provider Business Mailing Address
First Line	:	3200 COLD SPRING RD APT 220
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1960
Country	:	US
Telephone Number	:	317-361-5293
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 ALBANY ST
Second Line	:
City	:	BEECH GROVE
State	:	IN
Zip	:	46107-1536
Country	:	US
Telephone Number	:	317-782-7200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2020
Last Update Date	:	07/24/2020

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Directions to “ JEFF RUSS PT” Practice Location

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