MEDICARE: RUSSELL D EDGAR D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2207	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366411720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL D EDGAR D.C.

Provider Business Mailing Address
First Line	:	PO BOX 6931
Second Line	:
City	:	OCEAN ISLE BEACH
State	:	NC
Zip	:	28469-0931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6934 BEACH DR SW
Second Line	:	SUITE 2
City	:	OCEAN ISLE BEACH
State	:	NC
Zip	:	28469-5797
Country	:	US
Telephone Number	:	910-575-7809
Fax Number	:	910-575-7810

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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