Provider Demographics
NPI:1649221508
Name:HARRISON, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:HARRISON
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 1:915 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-5067
Mailing Address - Country:US
Mailing Address - Phone:563-243-2511
Mailing Address - Fax:563-243-0817
Practice Address - Street 1:1705 16TH AVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252-9708
Practice Address - Country:US
Practice Address - Phone:815-589-2121
Practice Address - Fax:815-589-4468
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0219477Medicaid
IA20317OtherWELLMARK BC/BS
018854OtherHEALTH ALLIANCE
18999OtherMIDLANDS CHOICE
27100OtherIOWA HEALTH SOLUTIOS
29840094OtherILLINOIS BCBS
IL036070350Medicaid
IA0118OtherJOHN DEERE HEALTH
IL09822109OtherBLUE CROSS BLUE SHIELD
018854OtherHEALTH ALLIANCE
IA20317Medicare PIN
IL09822109OtherBLUE CROSS BLUE SHIELD
IA0219477Medicaid
IA080013156Medicare PIN