Provider Demographics
NPI:1942249008
Name:HARRIS, RICHARD G (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
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 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1277
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:088-621-7817
Practice Address - Street 1:11250 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4116
Practice Address - Country:US
Practice Address - Phone:737-797-7500
Practice Address - Fax:773-779-9669
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110619Medicaid
IN200887790Medicaid
IL036110619Medicaid
ILK11522Medicare PIN
IN200887790Medicaid