Basic Information
| Provider Information | |||||||||
| NPI: | 1881601318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS, MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 GOOSE LANE | ||||||||
| Address2: | SUITE 2500 | ||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034530134 | ||||||||
| FaxNumber: | 2034530167 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 GOOSE LANE | ||||||||
| Address2: | STE 2500 | ||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034530134 | ||||||||
| FaxNumber: | 2034530167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4359 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080004359CT04 | 01 | CT | BLUE CROSS BLUE SHEILD | OTHER | 004133906 | 05 | CT | MEDICAID |