Provider Demographics
NPI:1043527195
Name:RUSSELL A FAIRBANKS, D.C.,P.C.
Entity Type:Organization
Organization Name:RUSSELL A FAIRBANKS, D.C.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-734-3384
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-0213
Mailing Address - Country:US
Mailing Address - Phone:989-734-3384
Mailing Address - Fax:989-734-7391
Practice Address - Street 1:408 N THIRD ST
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1309
Practice Address - Country:US
Practice Address - Phone:989-734-3384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G15000OtherBLUE CROSS
MI2967204Medicaid
MI2967204Medicaid
MIT33534Medicare UPIN