Basic Information
| Provider Information | |||||||||
| NPI: | 1073778635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCARA | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39 | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285570039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002280249 | ||||||||
| FaxNumber: | 2522223602 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E TICKLE ST | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380243120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002280249 | ||||||||
| FaxNumber: | 2522223602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD014365 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3003918 | 05 | TN | MEDICAID | 4052744 | 01 | TN | BLUE CROSS | OTHER |