Provider Demographics
NPI:1245204981
Name:HARRISON, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:HARRISON
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 1:4525 MID RIVERS MALL DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2820
Mailing Address - Country:US
Mailing Address - Phone:636-441-5437
Mailing Address - Fax:636-441-4398
Practice Address - Street 1:4525 MID RIVERS MALL DR
Practice Address - Street 2:SUITE 20
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63376-2820
Practice Address - Country:US
Practice Address - Phone:636-441-5437
Practice Address - Fax:636-441-4398
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1C73208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA13336Medicare UPIN