MEDICARE: RUSSELL FUNCHES PT

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	PT012482	OH
2	225100000X	Physical Therapist	PT 012482	OH

General Provider Information

NPI Number	:	1609297688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL FUNCHES PT

Provider Business Mailing Address
First Line	:	2219 E 73RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-4827
Country	:	US
Telephone Number	:	216-326-7487
Fax Number	:

Provider Business Practice Location Address
First Line	:	5908 LINWOOD AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-3012
Country	:	US
Telephone Number	:	216-326-7487
Fax Number	:

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

Provider Enumeration Date	:	12/18/2013
Last Update Date	:	03/15/2022

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