Healthcare Provider Details

I. General information

NPI: 1528172368
Provider Name (Legal Business Name): RUSSELL D. RADICAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PRIMACY PKWY SUITE 105
MEMPHIS TN
38119-0705
US

IV. Provider business mailing address

6100 PRIMACY PKWY SUITE 105
MEMPHIS TN
38119-0705
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-5335
  • Fax: 901-682-5440
Mailing address:
  • Phone: 901-682-5335
  • Fax: 901-682-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC1171
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberDC1171
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC1171
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: