Provider Demographics
NPI:1841579851
Name:HARRISON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:HARRISON MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-484-2584
Mailing Address - Street 1:332 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-1775
Mailing Address - Country:US
Mailing Address - Phone:973-484-9216
Mailing Address - Fax:973-484-9216
Practice Address - Street 1:332 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-1775
Practice Address - Country:US
Practice Address - Phone:973-484-9216
Practice Address - Fax:973-484-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08446200207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty