Provider Demographics
NPI:1073778635
Name:SCARA, RUSSELL G (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:G
Last Name:SCARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-0039
Mailing Address - Country:US
Mailing Address - Phone:800-228-0249
Mailing Address - Fax:252-222-3602
Practice Address - Street 1:400 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3120
Practice Address - Country:US
Practice Address - Phone:800-228-0249
Practice Address - Fax:252-222-3602
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD014365207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3003918Medicaid
TN4052744OtherBLUE CROSS
TN3003911Medicare PIN