Provider Demographics
NPI:1366411720
Name:EDGAR, RUSSELL D (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:EDGAR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6931
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-0931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6934 BEACH DR SW
Practice Address - Street 2:SUITE 2
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-5797
Practice Address - Country:US
Practice Address - Phone:910-575-7809
Practice Address - Fax:910-575-7810
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2207111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7908776Medicaid
NC2449892CMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
NC2340746Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
NC7908776Medicaid