Provider Demographics
NPI:1184874224
Name:PATRICIA HARRISON MD P L
Entity type:Organization
Organization Name:PATRICIA HARRISON MD P L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-862-4960
Mailing Address - Street 1:1025 N. BEAL PKWY
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1481
Mailing Address - Country:US
Mailing Address - Phone:850-862-4960
Mailing Address - Fax:850-862-4529
Practice Address - Street 1:1025 N. BEAL PKWY
Practice Address - Street 2:SUITE B-1
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1481
Practice Address - Country:US
Practice Address - Phone:850-862-4960
Practice Address - Fax:850-862-4529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71795261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253694300Medicaid
FL43326OtherBLUE CROSS BLUE SHIELD
FLDO896AMedicare PIN