Provider Demographics
NPI:1528643533
Name:PERNUS, RUSSELL SEAN
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:SEAN
Last Name:PERNUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 GENTRY CIR
Mailing Address - Street 2:
Mailing Address - City:CONCORD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-8938
Mailing Address - Country:US
Mailing Address - Phone:440-941-9628
Mailing Address - Fax:
Practice Address - Street 1:8532 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5822
Practice Address - Country:US
Practice Address - Phone:440-205-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRB912985171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator