1194801605 NPI number — DR. NEDRA J HARRISON MD FACS

Table of content: DR. NEDRA J HARRISON MD FACS (NPI 1194801605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194801605 NPI number — DR. NEDRA J HARRISON MD FACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRISON
Provider First Name:
NEDRA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FACS
Provider Gender Code:
F

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:
1194801605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 39179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85069-9179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-395-0718
Provider Business Mailing Address Fax Number:
602-277-8146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9220 E MOUNTAIN VIEW RD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85258-5134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-470-6888
Provider Business Practice Location Address Fax Number:
833-640-8848
Provider Enumeration Date:
10/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  28264 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01554248 . This is a "RR MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3721790 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 5250332 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".