Basic Information
| Provider Information | |||||||||
| NPI: | 1164409173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412761700 | ||||||||
| FaxNumber: | 5412766327 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SE COURT PL | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412761700 | ||||||||
| FaxNumber: | 5412766327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 23092 | NE | N | Other Service Providers | Military Health Care Provider | 207Q00000X | MD29141 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500606602 | 05 | OR | MEDICAID |