MEDICARE: MR. RUSSELL WADE STEPHAN MSM MPT

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	PT20296	FL

General Provider Information

NPI Number	:	1124191226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL WADE STEPHAN MSM MPT

Provider Business Mailing Address
First Line	:	9371 CYPRESS LAKE DR
Second Line	:	SUITE 20
City	:	FORT MYERS
State	:	FL
Zip	:	33919-4939
Country	:	US
Telephone Number	:	239-415-2595
Fax Number	:	239-415-2597

Provider Business Practice Location Address
First Line	:	9371 CYPRESS LAKE DR
Second Line	:	SUITE 20
City	:	FORT MYERS
State	:	FL
Zip	:	33919-4939
Country	:	US
Telephone Number	:	239-415-2595
Fax Number	:	239-415-2597

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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