1619165693 NPI number — HARRELSON FAMILY MEDICINE PC

Table of content: (NPI 1619165693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619165693 NPI number — HARRELSON FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARRELSON FAMILY MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619165693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1559 PROFESSIONAL PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36830-2858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-826-1121
Provider Business Mailing Address Fax Number:
334-826-1149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1559 PROFESSIONAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36830-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-826-1121
Provider Business Practice Location Address Fax Number:
334-826-1149
Provider Enumeration Date:
10/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRELSON
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
334-826-1121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  11448 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529913570 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051503715 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51503715 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com