Basic Information
| Provider Information | |||||||||
| NPI: | 1205858610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN-HARRISON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CAROLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRISON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FL, MSC9152 | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 08/21/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35-076532 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2138798 | 01 | OH | BCMH | OTHER | 000000189644 | 01 | OH | ANTHEM | OTHER | 2138798 | 05 | OH | MEDICAID | 000000525911 | 01 | OH | ANTHEM | OTHER | 363383 | 01 | OH | WELLCARE | OTHER | 000000221121 | 01 | OH | UNISON | OTHER | 1021101760001 | 01 | PA | PA MEDICAID | OTHER | 2467730 | 01 | OH | AETNA | OTHER | 738037 | 01 | OH | BUCKEYE | OTHER |