Provider Demographics
NPI:1003879586
Name:HARKLEROAD, MARY ELEANOR (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELEANOR
Last Name:HARKLEROAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1191
Mailing Address - Country:US
Mailing Address - Phone:270-651-7796
Mailing Address - Fax:
Practice Address - Street 1:411 S L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1191
Practice Address - Country:US
Practice Address - Phone:270-651-7796
Practice Address - Fax:270-651-7796
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45808207P00000X, 207Q00000X
GA053748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100220570Medicaid
GA93BBHQWMedicare ID - Type Unspecified