Provider Demographics
NPI:1619165693
Name:HARRELSON FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:HARRELSON FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-826-1121
Mailing Address - Street 1:1559 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2858
Mailing Address - Country:US
Mailing Address - Phone:334-826-1121
Mailing Address - Fax:334-826-1149
Practice Address - Street 1:1559 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-2858
Practice Address - Country:US
Practice Address - Phone:334-826-1121
Practice Address - Fax:334-826-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529913570Medicaid
AL051503715OtherMEDICARE PROVIDER NUMBER
AL51503715OtherBLUE CROSS