Provider Demographics
NPI:1336211226
Name:RUSSELL, HOWARD MICHAEL (LPT)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:MICHAEL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:ID
Mailing Address - Zip Code:83833-0198
Mailing Address - Country:US
Mailing Address - Phone:208-755-5704
Mailing Address - Fax:208-689-3183
Practice Address - Street 1:3325 POCAHONTAS ROAD
Practice Address - Street 2:ST ELIZABETH HEALTH SERVICES
Practice Address - City:BAKER CITY
Practice Address - State:ID
Practice Address - Zip Code:97814-1464
Practice Address - Country:US
Practice Address - Phone:541-523-8130
Practice Address - Fax:541-523-1793
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0287225100000X
IDPT1338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist