Healthcare Provider Details

I. General information

NPI: 1104812361
Provider Name (Legal Business Name): BENJAMIN L HARRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 NEWBERRY RD
WHIGHAM GA
39897-2924
US

IV. Provider business mailing address

458 NEWBERRY RD
WHIGHAM GA
39897-2924
US

V. Phone/Fax

Practice location:
  • Phone: 404-537-2221
  • Fax:
Mailing address:
  • Phone: 404-537-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number050525
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number101257079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: