Provider Demographics
NPI:1104812361
Name:HARRELL, BENJAMIN L (MD)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:L
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 1:458 NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:WHIGHAM
Mailing Address - State:GA
Mailing Address - Zip Code:39897-2924
Mailing Address - Country:US
Mailing Address - Phone:404-537-2221
Mailing Address - Fax:
Practice Address - Street 1:458 NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:WHIGHAM
Practice Address - State:GA
Practice Address - Zip Code:39897-2924
Practice Address - Country:US
Practice Address - Phone:404-537-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050525207Q00000X
VA101257079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000922215FMedicaid
GA00922215EMedicaid
GA08CBCFSMedicare ID - Type Unspecified
GAH47907Medicare UPIN
GA000922215FMedicaid