Provider Demographics
NPI:1245339944
Name:HARRIS, GARY B (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3000 WOODCREEK DR
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5401
Mailing Address - Country:US
Mailing Address - Phone:630-874-2994
Mailing Address - Fax:630-968-1622
Practice Address - Street 1:111 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4815
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036061845207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061845Medicaid
ILP00822024OtherRAILROAD MEDICARE
IL743830001Medicare PIN
E18579Medicare UPIN
IL217091004Medicare PIN