Basic Information
| Provider Information | |||||||||
| NPI: | 1225130800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | EMERSON | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1539 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317761539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298909148 | ||||||||
| FaxNumber: | 2298902166 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 31ST AVE SE | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919148 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 030316 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | BH1178082 | 01 | DEA | OTHER | G14912A | 01 | GA | MEDICARE | OTHER | 000502862U | 05 | GA | MEDICAID | P02319602 | 01 | GA | RAILROAD MCR | OTHER |