Provider Demographics
NPI:1154364180
Name:CLIFFORD, RUSSELL J (PT)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:J
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 38TH AVE N
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1536
Mailing Address - Country:US
Mailing Address - Phone:727-384-4111
Mailing Address - Fax:727-343-4803
Practice Address - Street 1:6701 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1536
Practice Address - Country:US
Practice Address - Phone:727-384-4111
Practice Address - Fax:727-343-4803
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT15543174400000X
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0035Medicare UPIN