Provider Demographics
NPI:1962029579
Name:HARRIS, NEELY TAYLOR ROSE (MD)
Entity Type:Individual
Prefix:
First Name:NEELY
Middle Name:TAYLOR ROSE
Last Name:HARRIS
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:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:
Practice Address - Street 1:1005 HEALTH CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4637
Practice Address - Country:US
Practice Address - Phone:217-258-4006
Practice Address - Fax:217-258-4120
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020018778208000000X
IL036-166678208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics