Provider Demographics
NPI:1699870204
Name:L'HOMMEDIEU, RUSS A (PT, MA)
Entity type:Individual
Prefix:
First Name:RUSS
Middle Name:A
Last Name:L'HOMMEDIEU
Suffix:
Gender:M
Credentials:PT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 CARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-1624
Mailing Address - Country:US
Mailing Address - Phone:631-765-8069
Mailing Address - Fax:
Practice Address - Street 1:633 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-7013
Practice Address - Country:US
Practice Address - Phone:631-477-6035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011600225100000X, 2251G0304X, 2251H1300X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Not Answered2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman Factors
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ86091Medicare ID - Type UnspecifiedPHYSICAL THERAPIST