Provider Demographics
NPI:1528018355
Name:FAIRBANKS, RUSSELL AUSTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:AUSTIN
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DC
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 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:989-734-7391
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2967204Medicaid
MI95OG150000OtherBLUE CROSSBLUESHIELD
MI95OG150000OtherBLUE CROSSBLUESHIELD
MI2967204Medicaid