1073007001 NPI number — JESSICA RUSSELL SILVER PT, DPT

Table of content: JESSICA RUSSELL SILVER PT, DPT (NPI 1073007001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073007001 NPI number — JESSICA RUSSELL SILVER PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SILVER
Provider First Name:
JESSICA
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSSELL
Provider Other First Name:
JESSICA
Provider Other Middle Name:
NATALIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073007001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14190 BALTIMORE AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20707-5098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-232-8234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  26441 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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