Provider Demographics
NPI:1285742742
Name:RUSSELL, SCOTT KEVIN (MPT)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:KEVIN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W J ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4069
Mailing Address - Country:US
Mailing Address - Phone:209-827-6178
Mailing Address - Fax:209-827-6179
Practice Address - Street 1:312 W J ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4073
Practice Address - Country:US
Practice Address - Phone:209-827-6178
Practice Address - Fax:209-827-6179
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0235970Medicaid
CAPT23597Medicare UPIN
CAPT23597Medicare UPIN
CAZZZ01542ZOtherBLUE SHIELD
CA0PT235970Medicare ID - Type UnspecifiedPHYSICAL THERAPIST