Basic Information
| Provider Information | |||||||||
| NPI: | 1649267956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMERSON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281641438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042638945 | ||||||||
| FaxNumber: | 7042632591 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281641438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042638945 | ||||||||
| FaxNumber: | 7042632591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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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 | 207Q00000X | 35636 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | N35636 | 05 | SC | MEDICAID | P00217229 | 01 | NC | RAILROAD MEDICARE | OTHER | 8930660 | 05 | NC | MEDICAID |