Provider Demographics
NPI:1063868164
Name:RUSS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:RUSS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-426-6334
Mailing Address - Street 1:1002 WESTPARK DR STE 6
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4283
Mailing Address - Country:US
Mailing Address - Phone:479-250-4014
Mailing Address - Fax:479-250-4015
Practice Address - Street 1:2070 MCKENZIE RD
Practice Address - Street 2:STE A
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0747
Practice Address - Country:US
Practice Address - Phone:479-250-4014
Practice Address - Fax:479-250-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158462721Medicaid