Healthcare Provider Details

I. General information

NPI: 1619948973
Provider Name (Legal Business Name): MICHAEL S. RUSSO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CHURCH TOWERS
HOBOKEN NJ
07030
US

IV. Provider business mailing address

864 BROADWAY
BAYONNE NJ
07002-3054
US

V. Phone/Fax

Practice location:
  • Phone: 201-401-9687
  • Fax:
Mailing address:
  • Phone: 201-339-1109
  • Fax: 908-353-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00991200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: