Basic Information
| Provider Information | |||||||||
| NPI: | 1982696498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MORRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRISON | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 E 4TH ST STE 440 | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 3147414947 | ||||||||
| Practice Location | |||||||||
| Address1: | 264 HIGHWAY 641 N | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315847942 | ||||||||
| FaxNumber: | 7315847965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD0000001677 | TN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5848609 | 01 | TN | AETNA | OTHER | 004006095 | 01 | TN | TENNCARE SELECT | OTHER | 200721045001 | 01 | TN | TRICARE | OTHER | 3723849 | 05 | TN | MEDICAID | 4266337 | 01 | TN | CIGNA | OTHER | P00193746 | 01 | TN | RAILROAD MEDICARE | OTHER | 004006095 | 01 | TN | ANTHEM BLUE CROSS BLUE SH | OTHER | 004006095 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 200721045 | 01 | TN | OMNICARE | OTHER | 200721045 | 01 | TN | HEALTH PARTNERS | OTHER | 200721045 | 01 | TN | BOILERMAKERS | OTHER |