Basic Information
Provider Information | |||||||||
NPI: | 1235158601 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUSS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | LOYD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 HEMPSTEAD AVE | ||||||||
Address2: | SUITE 258 | ||||||||
City: | ROCKVILLE CENTRE | ||||||||
State: | NY | ||||||||
PostalCode: | 115704033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5165363800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5441 N UNIVERSITY DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 330674640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9548039002 | ||||||||
FaxNumber: | 9549332305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 07/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 188435 | NY | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.