Provider Demographics
NPI:1245769165
Name:HARRIS, KEVIN BRIAN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRIAN
Last Name:HARRIS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504939207R00000X, 207RG0100X
390200000X
MN76595207R00000X
OH35.135409207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology