Provider Demographics
NPI:1245340223
Name:HARRISON, CHARLES R (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:STE 6300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-486-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICH070071207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0410745OtherBLUE CARE NETWORK
MI16-0410745-1OtherBCBS NUMBER
MICH070071OtherSTATE LICENSE
MI4399456Medicaid
MIG25383Medicare UPIN
MI0M51480Medicare ID - Type Unspecified