Provider Demographics
NPI:1346290673
Name:HARRIS, RICHARD GERALD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GERALD
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 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-5055
Mailing Address - Fax:708-338-2474
Practice Address - Street 1:501 W NORTH AVE STE 201
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1600
Practice Address - Country:US
Practice Address - Phone:708-450-5055
Practice Address - Fax:708-338-2474
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063183208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063183Medicaid
ILP00255232OtherRAILROAD MEDICARE
ILP00255232OtherRAILROAD MEDICARE
IL036063183Medicaid
K20466Medicare PIN
ILD15929Medicare UPIN