Provider Demographics
NPI:1154764405
Name:DR. RUSSELL B HARRISON, MD PC
Entity type:Organization
Organization Name:DR. RUSSELL B HARRISON, MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-215-1564
Mailing Address - Street 1:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0100
Mailing Address - Country:US
Mailing Address - Phone:541-215-1564
Mailing Address - Fax:541-215-1567
Practice Address - Street 1:1100 SOUTHGATE STE 2
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3971
Practice Address - Country:US
Practice Address - Phone:541-215-1564
Practice Address - Fax:541-215-1567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29141261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR147201Medicare PIN