Healthcare Provider Details

I. General information

NPI: 1871231381
Provider Name (Legal Business Name): RUSSELL EUGENE BRUCE ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 PIPER RD
WEST SPRINGFIELD MA
01089-1799
US

IV. Provider business mailing address

425 PIPER RD
WEST SPRINGFIELD MA
01089-1799
US

V. Phone/Fax

Practice location:
  • Phone: 413-263-3400
  • Fax:
Mailing address:
  • Phone: 413-263-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2302
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: