Provider Demographics
NPI:1023101334
Name:VICKIE N HARRELL MD PA
Entity type:Organization
Organization Name:VICKIE N HARRELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-913-0018
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-913-0018
Mailing Address - Fax:850-913-9137
Practice Address - Street 1:801 E 6TH STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401
Practice Address - Country:US
Practice Address - Phone:850-913-0018
Practice Address - Fax:850-913-9137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31748OtherBCBS FLORIDA
FL379777500Medicaid
FL31748OtherBCBS FLORIDA