MEDICARE: KIMBERLY RUSSO CASH 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	16429	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y68361	OTHER	MA	BLUECROSSBLUESHIELD

General Provider Information

NPI Number	:	1992827695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY RUSSO CASH PT

Provider Business Mailing Address
First Line	:	120 BANKS ST
Second Line	:
City	:	WINTHROP
State	:	MA
Zip	:	02152-1931
Country	:	US
Telephone Number	:	617-846-5609
Fax Number	:	617-539-0025

Provider Business Practice Location Address
First Line	:	120 BANKS ST
Second Line	:
City	:	WINTHROP
State	:	MA
Zip	:	02152-1931
Country	:	US
Telephone Number	:	617-846-5609
Fax Number	:	617-539-0025

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	12/12/2007

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Directions to “ KIMBERLY RUSSO CASH PT” Practice Location

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