MEDICARE: DR. ELISABETH MARIE RUSSELL PT, 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	PT31564	FL

General Provider Information

NPI Number	:	1780035881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISABETH MARIE RUSSELL PT, DPT

Provider Business Mailing Address
First Line	:	8219 SOLANO BAY LOOP
Second Line	:	APT 1033
City	:	TAMPA
State	:	FL
Zip	:	33635-9573
Country	:	US
Telephone Number	:	585-281-4754
Fax Number	:

Provider Business Practice Location Address
First Line	:	4107 N HIMES AVE
Second Line	:	STE 110
City	:	TAMPA
State	:	FL
Zip	:	33607-6655
Country	:	US
Telephone Number	:	813-874-1009
Fax Number	:	813-872-6717

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

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	06/29/2016

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