Provider Demographics
NPI:1275644361
Name:HARRISON, STEPHEN RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7301 N SHADELAND AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2085
Mailing Address - Country:US
Mailing Address - Phone:317-577-1800
Mailing Address - Fax:317-577-1805
Practice Address - Street 1:7301 N SHADELAND AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2085
Practice Address - Country:US
Practice Address - Phone:317-577-1800
Practice Address - Fax:317-577-1805
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004122A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201121270Medicaid
IN201121270Medicaid
IN256870002Medicare PIN
MI4747961Medicaid