Basic Information
| Provider Information | |||||||||
| NPI: | 1811945801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 MIRABEAU ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451231617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379812116 | ||||||||
| FaxNumber: | 9379819238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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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 | 207R00000X | 34004098H | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000319610 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 0631990 | 05 | OH | MEDICAID |