Provider Demographics
NPI:1033221353
Name:HARRIMAN, CHARLES S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:HARRIMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 CITY ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-0974
Mailing Address - Country:US
Mailing Address - Phone:573-336-5100
Mailing Address - Fax:573-336-3118
Practice Address - Street 1:608 CITY BUSINESS ROUTE 66
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-0974
Practice Address - Country:US
Practice Address - Phone:553-336-5100
Practice Address - Fax:573-336-3118
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204890800Medicaid
431560263OtherTRICARE WEST
126882OtherBLUE CROSS MO
MO132680014Medicare PIN
003013123Medicare PIN
G16604Medicare UPIN
126882OtherBLUE CROSS MO
MO204890800Medicaid