Provider Demographics
NPI:1477521094
Name:CLINTON J HARRIS, MD, PLC
Entity Type:Organization
Organization Name:CLINTON J HARRIS, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-949-4971
Mailing Address - Street 1:3600 E FULTON
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-1322
Mailing Address - Country:US
Mailing Address - Phone:616-949-4971
Mailing Address - Fax:616-248-3530
Practice Address - Street 1:3600 E FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-1322
Practice Address - Country:US
Practice Address - Phone:616-949-4971
Practice Address - Fax:616-248-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA2804OtherRAILROAD MEDICARE
MI500D116030OtherBCBSM
0N84440Medicare PIN
MI500D116030OtherBCBSM