Healthcare Provider Details

I. General information

NPI: 1699797035
Provider Name (Legal Business Name): RUSSELL GLENN STEVES M.ED., PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FACULTY ROAD CALDWELL FIELDHOUSE PRINCETON UNIVERSITY
PRINCETON NJ
08544-0001
US

IV. Provider business mailing address

15 UNIVERSITY PL APT 1-N
PRINCETON NJ
08540-5154
US

V. Phone/Fax

Practice location:
  • Phone: 609-258-3527
  • Fax: 609-258-7045
Mailing address:
  • Phone: 609-430-0376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number40QA00378200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: