Provider Demographics
NPI:1194940650
Name:R BRENT HARBIN DPM PLLC
Entity type:Organization
Organization Name:R BRENT HARBIN DPM PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:HARBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:865-977-1316
Mailing Address - Street 1:616 W LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-3904
Mailing Address - Country:US
Mailing Address - Phone:865-977-1316
Mailing Address - Fax:865-977-8742
Practice Address - Street 1:616 W LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3904
Practice Address - Country:US
Practice Address - Phone:865-977-1316
Practice Address - Fax:865-977-8742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000559213E00000X
TNDPM559213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3353534Medicaid
TN6236810001Medicare NSC
TN3353269Medicare PIN
TNU80724Medicare UPIN