MEDICARE: MR. JEFFREY ALAN RUSSELL PT, MS,

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7458	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053497065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY ALAN RUSSELL PT, MS,

Provider Business Mailing Address
First Line	:	PO BOX 743
Second Line	:
City	:	WINTER PARK
State	:	CO
Zip	:	80482-0743
Country	:	US
Telephone Number	:	970-531-1582
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 TRESTLE DRIVE
Second Line	:
City	:	WINTER PARK
State	:	CO
Zip	:	80482-8048
Country	:	US
Telephone Number	:	970-531-1582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/22/2021

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