Provider Demographics
NPI:1295703098
Name:RUSS, JIM
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:
Last Name:RUSS
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 1:113 JOYCE CTR
Mailing Address - Street 2:
Mailing Address - City:NOTRE DAME
Mailing Address - State:IN
Mailing Address - Zip Code:46556-5678
Mailing Address - Country:US
Mailing Address - Phone:574-631-3304
Mailing Address - Fax:574-631-3305
Practice Address - Street 1:113 JOYCE CTR
Practice Address - Street 2:
Practice Address - City:NOTRE DAME
Practice Address - State:IN
Practice Address - Zip Code:46556-5678
Practice Address - Country:US
Practice Address - Phone:574-631-3304
Practice Address - Fax:574-631-3305
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000278A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer