Provider Demographics
NPI:1073541025
Name:HARRIS, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37909207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50031148OtherPASSPORT & PASSPORT ADVTG - NCVA
IN200440800AMedicaid
IN200440800FMedicaid
KYP00889594OtherMEDICARE RR - NCVA
KY000000693034OtherANTHEM - NCVA
KY000000293959OtherANTHEM PIN
KY64064793Medicaid
KY000057080FOtherHUMANA - NCVA
KY50000954OtherPASSPORT PIN
KY2442609000OtherPASSPORT ADVANTAGE PIN
KYH81783Medicare UPIN
KY0558611Medicare ID - Type Unspecified
KY0259840Medicare ID - Type Unspecified
KY64064793Medicaid
IN200440800FMedicaid
KYP400031684Medicare PIN
KY2442609000OtherPASSPORT ADVANTAGE PIN
KY000057080FOtherHUMANA - NCVA
KY0558320Medicare ID - Type Unspecified
KY0558217Medicare ID - Type Unspecified
IN200440800AMedicaid
KYP00004216Medicare PIN