Provider Demographics
NPI:1578512083
Name:HARRELSON, RICK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:ALAN
Last Name:HARRELSON
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 1:101 PROFESSIONAL LANE
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330
Mailing Address - Country:US
Mailing Address - Phone:334-347-3404
Mailing Address - Fax:334-693-0613
Practice Address - Street 1:101 PROFESSIONAL LANE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-347-3404
Practice Address - Fax:334-693-0613
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00017429207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51028525OtherBLUE CROSS BLUE SHIELD
AL000028525Medicaid
AL51028525OtherBLUE CROSS BLUE SHIELD
F58173Medicare UPIN
AL000028525Medicaid