Provider Demographics
NPI:1528243805
Name:HARRISON, GENIEL (MD)
Entity type:Individual
Prefix:
First Name:GENIEL
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5319
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-200-5383
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-200-5383
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42770207P00000X, 207QA0505X
ND11036207Q00000X
SD7267207Q00000X
MN50846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8EJ066Medicaid
AZ030078Medicare Oscar/Certification
AZ451523OtherAHCCCC
AZ8HK060Medicaid
AZ8HK061Medicaid
AZ8HK062Medicaid
ND8HI364Medicare PIN
1528243805OtherBCBS