Provider Demographics
NPI:1689235707
Name:HARRIS, MADELINE (C-AA)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:C-AA
Other - Prefix:MS
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:FORTUNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:C-AA
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3888
Mailing Address - Fax:419-383-2860
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3888
Practice Address - Fax:419-383-2860
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000344367H00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology