Provider Demographics
NPI:1366496457
Name:CHEANEY, RUSSELL ALAN (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALAN
Last Name:CHEANEY
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 890561
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0561
Mailing Address - Country:US
Mailing Address - Phone:800-919-1190
Mailing Address - Fax:706-737-2272
Practice Address - Street 1:3333 CATTLEMEN RD STE 100
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6057
Practice Address - Country:US
Practice Address - Phone:941-379-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29897207LP2900X
FLME138842207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22112OtherBCBSNC
SCN29897Medicaid
NC8922112Medicaid
NC1141346001OtherCIGNA
NC4597856OtherAETNA
NC80413OtherMEDCOST
NC050032552OtherRAILROAD MEDICARE
NC205381Medicare PIN