Provider Demographics
NPI:1659397495
Name:HARRELL, SAMPSON EMANUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMPSON
Middle Name:EMANUEL
Last Name:HARRELL
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 1:702 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4755
Mailing Address - Country:US
Mailing Address - Phone:336-599-9271
Mailing Address - Fax:336-599-0969
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4755
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-599-0969
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17981208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8939668Medicaid
NCC84349Medicare UPIN
NC207045Medicare ID - Type Unspecified