Provider Demographics
NPI:1841220134
Name:TIMOTHY C HARRELL, MD, PA
Entity Type:Organization
Organization Name:TIMOTHY C HARRELL, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-776-1190
Mailing Address - Street 1:5700 N FEDERAL HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2600
Mailing Address - Country:US
Mailing Address - Phone:954-776-1190
Mailing Address - Fax:954-776-1196
Practice Address - Street 1:5700 N FEDERAL HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2600
Practice Address - Country:US
Practice Address - Phone:954-776-1190
Practice Address - Fax:954-776-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0024306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58460Medicare UPIN
FL78370AMedicare ID - Type Unspecified