Basic Information
| Provider Information | |||||||||
| NPI: | 1366496457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEANEY | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890561 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009191190 | ||||||||
| FaxNumber: | 7067372272 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 CATTLEMEN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342326057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413795884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 29897 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | ME138842 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 22112 | 01 | NC | BCBSNC | OTHER | N29897 | 05 | SC | MEDICAID | 8922112 | 05 | NC | MEDICAID | 1141346001 | 01 | NC | CIGNA | OTHER | 4597856 | 01 | NC | AETNA | OTHER | 80413 | 01 | NC | MEDCOST | OTHER | 050032552 | 01 | NC | RAILROAD MEDICARE | OTHER |