MEDICARE: DR. RUSSELL AUSTIN FAIRBANKS 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	2301005062	MI

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
2	95OG150000	OTHER	MI	BLUE CROSSBLUESHIELD

General Provider Information

NPI Number	:	1528018355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL AUSTIN FAIRBANKS D.C.

Provider Business Mailing Address
First Line	:	PO BOX 213
Second Line	:
City	:	ROGERS CITY
State	:	MI
Zip	:	49779-0213
Country	:	US
Telephone Number	:	989-734-3384
Fax Number	:	989-734-7391

Provider Business Practice Location Address
First Line	:	408 N THIRD ST
Second Line	:
City	:	ROGERS CITY
State	:	MI
Zip	:	49779-1309
Country	:	US
Telephone Number	:	989-734-3384
Fax Number	:	989-734-7391

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	06/14/2011

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