Basic Information
| Provider Information | |||||||||
| NPI: | 1083716476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125672000 | ||||||||
| FaxNumber: | 3123287724 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036073471 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036073471 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036073471 | 05 | IL | MEDICAID | 0031603775 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |