Basic Information
| Provider Information | |||||||||
| NPI: | 1447227087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 REID PKWY | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659833293 | ||||||||
| FaxNumber: | 7659833219 | ||||||||
| Practice Location | |||||||||
| Address1: | 4166 HIGHLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659936413 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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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 | 225100000X | 05006801A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 009254 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1311760 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000907335 | 01 | ANTHEM | OTHER | 0116838 | 05 | OH | MEDICAID | 201265350 | 05 | IN | MEDICAID |