=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902161672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSY RUSSELL PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2012
-----------------------------------------------------
Last Update Date | 10/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040 BERKMAR DR STE A1
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-1593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-249-9578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3040 BERKMAR DR STE A1
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-1593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-249-9578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSANNE RUSSELL
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 434-249-9578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 2305003603
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------