Provider Demographics
NPI:1689631582
Name:HARRISON, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
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 1:706 DIXIE ST STE 220
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3889
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:1480 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-8901
Practice Address - Country:US
Practice Address - Phone:770-836-9445
Practice Address - Fax:770-836-8808
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050634207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA750276254BMedicaid
SCAA33487919Medicare PIN
GAE66171Medicare UPIN
SCAA33489075Medicare PIN
GA93BBHNTMedicare ID - Type Unspecified705 DIXIE ST