Provider Demographics
NPI:1104825892
Name:HARRISON, GREGORY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 4168
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4168
Mailing Address - Country:US
Mailing Address - Phone:208-239-2055
Mailing Address - Fax:208-239-3754
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:SUITE 115
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2260
Practice Address - Fax:208-239-3767
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN44711207T00000X
IDM11193207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH57419Medicare UPIN