Provider Demographics
NPI:1518954262
Name:HARRIS, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
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 1:274 KELL AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4114
Mailing Address - Country:US
Mailing Address - Phone:718-761-5356
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:ROOM 344 CHC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5126
Practice Address - Fax:718-240-6550
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-28
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171448208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01252886Medicaid
06575GOtherGHS
E48828Medicare UPIN
NYF3Z111Medicare ID - Type Unspecified