Provider Demographics
NPI:1760412548
Name:HARRIS, CORRIE A (MD)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CORRIE
Other - Middle Name:A
Other - Last Name:GOERGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0324
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-629-6000
Practice Address - Fax:502-629-5991
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246114208000000X
KY46086208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100253700Medicaid
IN201201690Medicaid