Basic Information
| Provider Information | |||||||||
| NPI: | 1528009719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6033 COWELL RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481169109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493485 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16001 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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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 | 207PE0004X | 4301049889 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | MH049889 | 01 | MI | BC/BS OF MICHIGAN | OTHER | 103374784 | 05 | MI | MEDICAID | 104288644 | 05 | MI | MEDICAID | 104274916 | 05 | MI | MEDICAID |