Provider Demographics
NPI:1649228750
Name:HARRIS, PHILLIP GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GORDON
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 1:1403 S KING ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-9666
Mailing Address - Country:US
Mailing Address - Phone:252-794-6775
Mailing Address - Fax:252-794-6771
Practice Address - Street 1:1403 S KING ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9666
Practice Address - Country:US
Practice Address - Phone:252-794-6775
Practice Address - Fax:252-794-6771
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8944403OtherMEDICAID
NC39985OtherBCBS
NC39985OtherBCBS
2182373PMedicare PIN