Provider Demographics
NPI:1295796316
Name:HARISH, AVVERAHALLI M (MD)
Entity type:Individual
Prefix:
First Name:AVVERAHALLI
Middle Name:M
Last Name:HARISH
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 1:5401 OLD COURT RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:5310 OLD COURT RD
Practice Address - Street 2:SUITE 303
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5243
Practice Address - Country:US
Practice Address - Phone:410-655-0312
Practice Address - Fax:410-655-0497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD42723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD951M754FMedicare ID - Type Unspecified
MDF73012Medicare UPIN