Provider Demographics
NPI:1518920073
Name:HARRISON, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-438-5670
Mailing Address - Fax:618-438-5709
Practice Address - Street 1:203 BAILEY LN STE 1
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-2266
Practice Address - Country:US
Practice Address - Phone:618-438-5670
Practice Address - Fax:618-438-5709
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111745Medicaid
IL036111745Medicaid
212543Medicare PIN
IL214881076Medicare PIN
ILI19562Medicare UPIN
ILK12684Medicare ID - Type Unspecified