Provider Demographics
NPI:1144219098
Name:POOLE, RUSSELL (PT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:POOLE
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 1:3425 N CARLISLE ST
Mailing Address - Street 2:2ND FLOOR, HUDSON BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5108
Mailing Address - Country:US
Mailing Address - Phone:215-707-4739
Mailing Address - Fax:215-707-3677
Practice Address - Street 1:75 EVELYN DR
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17061-1258
Practice Address - Country:US
Practice Address - Phone:717-692-4708
Practice Address - Fax:717-692-5464
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002288L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
154688Medicare ID - Type Unspecified
Q14789Medicare UPIN