Basic Information
| Provider Information | |||||||||
| NPI: | 1003137571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARSONO | ||||||||
| FirstName: | MIMILY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF TENNESSEE (DIVISION OF NEONATOLOGY) | ||||||||
| Address2: | 853 JEFFERSON AVE, SUITE-201, NEWBORN CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014485950 | ||||||||
| FaxNumber: | 9014481691 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY OF TENNESSEE (DIVISION OF NEONATOLOGY) | ||||||||
| Address2: | 853 JEFFERSON AVENUE, SUITE-201, NEWBORN CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014485950 | ||||||||
| FaxNumber: | 9014481691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2010 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 50025 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02507295 | 05 | MS | MEDICAID | 1003137571 | 05 | MI | MEDICAID | 177423 | 05 | AL | MEDICAID | 197560001 | 05 | AR | MEDICAID | 00179412A | 05 | GA | MEDICAID | 1532008 | 05 | TN | MEDICAID | 1003137571 | 05 | MO | MEDICAID |