Provider Demographics
NPI:1043283492
Name:HARRIS, BASIL M (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:M
Last Name:HARRIS
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:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:800-456-4629
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:100 WEST LANCASTER AVENUE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:610-645-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424860207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013262340001Medicaid
PA1013262340001Medicaid
PA092383Medicare ID - Type Unspecified