Healthcare Provider Details

I. General information

NPI: 1144219098
Provider Name (Legal Business Name): RUSSELL POOLE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EVELYN DR
MILLERSBURG PA
17061-1258
US

IV. Provider business mailing address

3425 N CARLISLE ST 2ND FLOOR, HUDSON BUILDING
PHILADELPHIA PA
19140-5108
US

V. Phone/Fax

Practice location:
  • Phone: 717-692-4708
  • Fax: 717-692-5464
Mailing address:
  • Phone: 215-707-4739
  • Fax: 215-707-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002288L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: