Provider Demographics
NPI:1780624932
Name:HARRELL, GARY M (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
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 1:8337 WYCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-2597
Mailing Address - Country:US
Mailing Address - Phone:513-272-1958
Mailing Address - Fax:
Practice Address - Street 1:989 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8750
Practice Address - Country:US
Practice Address - Phone:606-759-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0928447Medicaid
OH0928447Medicaid
HA4167062Medicare ID - Type Unspecified