Healthcare Provider Details

I. General information

NPI: 1871575852
Provider Name (Legal Business Name): BERNARD GAYLE HARRELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 HIGHWAY 35 S
FOREST MS
39074-9423
US

IV. Provider business mailing address

PO BOX 5183
MERIDIAN MS
39302-5183
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-3555
  • Fax: 601-469-3584
Mailing address:
  • Phone: 601-703-9506
  • Fax: 601-703-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10830
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: