Provider Demographics
NPI:1033150792
Name:HARRIS, TASHA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TASHA
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 WICKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-365-7620
Mailing Address - Fax:219-226-2287
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:ST. JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-365-7620
Practice Address - Fax:219-226-2287
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103616207P00000X
IN01056752A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103616Medicaid
P00140143Medicare ID - Type UnspecifiedRAILROAD MEDICARE
K05781Medicare ID - Type Unspecified
H34423Medicare UPIN