Healthcare Provider Details

I. General information

NPI: 1164409173
Provider Name (Legal Business Name): RUSSELL B HARRISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SE COURT PL SUITE 201
PENDLETON OR
97801
US

IV. Provider business mailing address

PO BOX 190
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-1700
  • Fax: 541-276-6327
Mailing address:
  • Phone: 541-276-1700
  • Fax: 541-276-6327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number23092
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD29141
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: