MEDICARE: MR. MATTHEW THOMAS RUSSELL PTA

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	225200000X	Physical Therapy Assistant	001809-1	NY

General Provider Information

NPI Number	:	1407989445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW THOMAS RUSSELL PTA

Provider Business Mailing Address
First Line	:	PO BOX 673
Second Line	:
City	:	GOSHEN
State	:	NY
Zip	:	10924-0673
Country	:	US
Telephone Number	:	845-294-5065
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 HILL BLVD
Second Line	:	SUITE P
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-1293
Country	:	US
Telephone Number	:	914-962-2728
Fax Number	:	914-962-1729

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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