Basic Information
Provider Information | |||||||||
NPI: | 1073500765 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARISIDDAIAH | ||||||||
FirstName: | HARISH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2240 REMOUNT RD | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280544725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046715311 | ||||||||
FaxNumber: | 7046715308 | ||||||||
Practice Location | |||||||||
Address1: | 2711 X RAY DR | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280547491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048342465 | ||||||||
FaxNumber: | 7048342466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2005 | ||||||||
LastUpdateDate: | 09/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD61064980 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 9500993 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 8954784 | 05 | NC |   | MEDICAID | N00993 | 05 | SC |   | MEDICAID |