1508826207 NPI number — SUSAN M HARRIS NP

Table of content: SUSAN M HARRIS NP (NPI 1508826207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508826207 NPI number — SUSAN M HARRIS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508826207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-621-6300
Provider Business Mailing Address Fax Number:
317-621-6310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8202 CLEARVISTA PKWY
Provider Second Line Business Practice Location Address:
SUITE 7A
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-6300
Provider Business Practice Location Address Fax Number:
317-621-6310
Provider Enumeration Date:
03/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  71000009A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000655113 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000659326 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000655709 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000667919 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200963890 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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