Basic Information
| Provider Information | |||||||||
| NPI: | 1396740940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENNIS | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5 EXECUTIVE CIR | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126911533 | ||||||||
| FaxNumber: | 9126911953 | ||||||||
| Practice Location | |||||||||
| Address1: | 4815 OLEANDER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284035108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104521111 | ||||||||
| FaxNumber: | 9104525897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2005 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 66500 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1396740940 | 01 | NC | NPI | OTHER | 8939690 | 05 | NC | MEDICAID | 0106F | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |