Basic Information
| Provider Information | |||||||||
| NPI: | 1669761136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HARRISON | ||||||||
| OtherFirstName: | MARY BETH | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 511 OAKWOOD BLVD. | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786814068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122443698 | ||||||||
| FaxNumber: | 5122440214 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 OAKWOOD BLVD. | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786814068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122443698 | ||||||||
| FaxNumber: | 5122440214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Q5423 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 350006801 | 05 | TX | MEDICAID |