Basic Information
| Provider Information | |||||||||
| NPI: | 1265403265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 OLD SYMSONIA RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420255042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705274800 | ||||||||
| FaxNumber: | 2705274910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20594 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 20594 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64205941 | 05 | KY | MEDICAID |