Provider Demographics
NPI:1710973128
Name:HARRISON, MICHELLE R (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5572
Practice Address - Country:US
Practice Address - Phone:620-275-9752
Practice Address - Fax:620-275-4306
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049107A207V00000X
KS04-49028207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200190940Medicaid
163130DMedicare PIN
INM400042449Medicare PIN
IN200190940Medicaid
234340DMedicare PIN