Healthcare Provider Details

I. General information

NPI: 1235158601
Provider Name (Legal Business Name): MICHAEL LOYD RUSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 N UNIVERSITY DR STE 101
CORAL SPRINGS FL
33067-4640
US

IV. Provider business mailing address

30 HEMPSTEAD AVE SUITE 258
ROCKVILLE CENTRE NY
11570-4033
US

V. Phone/Fax

Practice location:
  • Phone: 954-803-9002
  • Fax: 954-933-2305
Mailing address:
  • Phone: 516-536-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number188435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: