MEDICARE: SAMANTHA ARIEL RUSSO DPT

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	0420841	NY

General Provider Information

NPI Number	:	1053830364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ARIEL RUSSO DPT

Provider Business Mailing Address
First Line	:	234 SARA CT
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-3839
Country	:	US
Telephone Number	:	914-500-7890
Fax Number	:

Provider Business Practice Location Address
First Line	:	2051 BALDWIN RD # 101
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-4047
Country	:	US
Telephone Number	:	914-302-2190
Fax Number	:

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

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	09/18/2017

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