Provider Demographics
NPI:1306189790
Name:HARRIS, BHRANDON (MD)
Entity Type:Individual
Prefix:DR
First Name:BHRANDON
Middle Name:
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 1:1919 W TAYLOR ST
Mailing Address - Street 2:SUITE 153
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 W TAYLOR ST
Practice Address - Street 2:SUITE 153
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7246
Practice Address - Country:US
Practice Address - Phone:312-413-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL036140660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program