Provider Demographics
NPI:1528172368
Name:RADICAN, RUSSELL D (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:RADICAN
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 1:6100 PRIMACY PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0705
Mailing Address - Country:US
Mailing Address - Phone:901-682-5335
Mailing Address - Fax:901-682-5440
Practice Address - Street 1:6100 PRIMACY PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0705
Practice Address - Country:US
Practice Address - Phone:901-682-5335
Practice Address - Fax:901-682-5440
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC1171111NS0005X, 111NX0100X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Not Answered111NX0100XChiropractic ProvidersChiropractorOccupational Health
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN61387800-03OtherCIGNA
TN5829049OtherAETNA HMO
TN61387800-04OtherCIGNA HMO
TN3009201OtherBLUECROSSBLUESHIELD
TNU54784Medicare UPIN
TN3677633Medicare ID - Type Unspecified