1184874224 NPI number — PATRICIA HARRISON MD P L

Table of content: (NPI 1184874224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184874224 NPI number — PATRICIA HARRISON MD P L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRICIA HARRISON MD P L
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:
1184874224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 N. BEAL PKWY
Provider Second Line Business Mailing Address:
SUITE B-1
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-1481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-862-4960
Provider Business Mailing Address Fax Number:
850-862-4529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 N. BEAL PKWY
Provider Second Line Business Practice Location Address:
SUITE B-1
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547-1481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-4960
Provider Business Practice Location Address Fax Number:
850-862-4529
Provider Enumeration Date:
09/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HARRISON
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
850-862-4960

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  ME71795 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 253694300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43326 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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