MEDICARE: THERON HARRISON, D.O., PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	051143	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518140524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERON HARRISON, D.O., PC

Provider Business Mailing Address
First Line	:	PO BOX 1329
Second Line	:
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31059-1329
Country	:	US
Telephone Number	:	478-453-3532
Fax Number	:	478-453-4496

Provider Business Practice Location Address
First Line	:	108 FIELDSTONE DR
Second Line	:
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061-7110
Country	:	US
Telephone Number	:	478-453-3532
Fax Number	:	478-453-4496

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	DR. THERON GERARD HARRISON
Credential	:	D.O.
Telephone Number	:	478-453-3532

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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