Basic Information
| Provider Information | |||||||||
| NPI: | 1023172392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES R HARRIS & ASSOCIATES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10628 S LONGWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606432617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129694333 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Practice Location | |||||||||
| Address1: | 10628 S LONGWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606432617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129694333 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3129694333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036060209 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 036060209 | 05 | IL | MEDICAID |