Provider Demographics
NPI:1063421246
Name:SWANN, EDWIN RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:RUSSELL
Last Name:SWANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4822 SIX FORKS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5269
Mailing Address - Country:US
Mailing Address - Phone:919-782-4933
Mailing Address - Fax:919-782-4934
Practice Address - Street 1:4822 SIX FORKS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5269
Practice Address - Country:US
Practice Address - Phone:919-782-4933
Practice Address - Fax:919-782-4934
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC21724207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8981125Medicaid
NC202759Medicare ID - Type Unspecified
NC8981125Medicaid