Provider Demographics
NPI:1154346310
Name:RUSSELL, C THOMAS D (CH)
Entity type:Individual
Prefix:
First Name:C THOMAS
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-4849
Mailing Address - Country:US
Mailing Address - Phone:828-328-2551
Mailing Address - Fax:828-328-2955
Practice Address - Street 1:912 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-4849
Practice Address - Country:US
Practice Address - Phone:828-328-2551
Practice Address - Fax:828-328-2955
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0194LOtherCNC
NC08779OtherBC/BS OF NC
NC8908779Medicaid
NCT64241Medicare UPIN
NC244158Medicare PIN