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General NPI Number Information
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NPI Number | 1104424167
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Entity Type | Individual
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Provider Name | ELIZABETH RUSTOM DPT
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Gender | Female
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Dates
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Enumeration Date | 10/13/2020
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Last Update Date | 10/13/2020
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Provider Practice Location Address
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Address Line | 4036 HIGHWAY 8
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City | CLEVELAND
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State | MS
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Zip | 38732-8551
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Country | US
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Telephone | 662-843-4014
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 428
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City | ORCHARD PARK
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State | NY
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Zip | 14127-0428
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Country | US
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Telephone | 716-662-4955
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 6773
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License Number State | MS
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