Provider Demographics
NPI:1972694685
Name:HARRIS, ANGIE MILLS (DO)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:MILLS
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DR STE 220
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-474-1723
Mailing Address - Fax:
Practice Address - Street 1:2 MEMORIAL DR STE 220
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-474-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139138207Q00000X
GA059470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7843Medicare PIN
GAH84732Medicare UPIN
GA200864966AMedicaid