Provider Demographics
NPI:1902887375
Name:ANNIS, RUSSELL JAMES JR (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JAMES
Last Name:ANNIS
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:1639 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201
Practice Address - Country:US
Practice Address - Phone:812-669-1687
Practice Address - Fax:812-775-1035
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003020A225100000X
VA2305207421225100000X
OHPT-04982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01118235Medicare PIN