Healthcare Provider Details

I. General information

NPI: 1215976493
Provider Name (Legal Business Name): ROBERT RUSSO JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 ACME RD
FRANKFORT NY
13340-3504
US

IV. Provider business mailing address

4266 ACME RD
FRANKFORT NY
13340-3504
US

V. Phone/Fax

Practice location:
  • Phone: 315-895-0012
  • Fax: 315-444-8000
Mailing address:
  • Phone: 315-895-0012
  • Fax: 315-444-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number028070
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: