Active NPI
Antonino Roberto Russo
- Physical Therapist
- Burley, ID
National Provider Identifier
1316604937
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- PT-7636
- Practice address
- 1945 Hiland Ave
Burley, ID 83318-2714 - Phone
- (208) 647-0024
- NPI assigned
- Nov 18, 2021
- Last updated
- Nov 18, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | PT-7636 | ID | Primary |
Addresses
Primary practice location
1945 Hiland Ave
Burley, ID 83318-2714
Mailing address
1411 Falls Ave E Ste 401
Twin Falls, ID 83301-3455
Phone (208) 647-0024
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
Care Compare profile
Medicare Care Compare- Specialty
- Physical Therapist in Private Practice
- Education
- Other, 2021
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
1411 Falls Ave E
Suite 401
Twin Falls, ID 83301-3455
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT-7636 | ID | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1637193600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1637193600000",
"number": "1316604937",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1411 FALLS AVE E STE 401",
"city": "TWIN FALLS",
"state": "ID",
"postal_code": "833013455",
"telephone_number": "208-647-0024",
"fax_number": "208-647-0239"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1945 HILAND AVE",
"city": "BURLEY",
"state": "ID",
"postal_code": "833182714",
"telephone_number": "208-647-0024"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSO",
"first_name": "ANTONINO",
"middle_name": "ROBERTO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-11-18",
"last_updated": "2021-11-18",
"certification_date": "2021-11-18",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "ID",
"license": "PT-7636",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Burley, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.