Provider Demographics
NPI:1649267956
Name:EMERSON, RUSSELL IAN (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:IAN
Last Name:EMERSON
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 1:700 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-1438
Mailing Address - Country:US
Mailing Address - Phone:704-263-8945
Mailing Address - Fax:704-263-2591
Practice Address - Street 1:700 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-1438
Practice Address - Country:US
Practice Address - Phone:704-263-8945
Practice Address - Fax:704-263-2591
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN35636Medicaid
NCP00217229OtherRAILROAD MEDICARE
NC8930660Medicaid
NC2176644AMedicare PIN
NCF39883Medicare UPIN