Healthcare Provider Details

I. General information

NPI: 1104825892
Provider Name (Legal Business Name): GREGORY S HARRISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY SUITE 115
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

PO BOX 4168
POCATELLO ID
83205-4168
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-2260
  • Fax: 208-239-3767
Mailing address:
  • Phone: 208-239-2055
  • Fax: 208-239-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number44711
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberM11193
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: