Provider Demographics
NPI:1770763443
Name:W RICHARD HARRIS MD LLC
Entity type:Organization
Organization Name:W RICHARD HARRIS MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-865-6428
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1148
Mailing Address - Country:US
Mailing Address - Phone:231-727-5081
Mailing Address - Fax:
Practice Address - Street 1:4295 FARR RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9753
Practice Address - Country:US
Practice Address - Phone:231-865-6428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0806136201OtherBLUE CROSS BLUE SHIELD
MI104233136Medicaid
MI0N16310Medicare PIN
MI104233136Medicaid