Provider Demographics
NPI:1336533264
Name:HARRISON, MARGO HELENE (DO)
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:HELENE
Last Name:HARRISON
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 1:4235 N DAMEN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3011
Mailing Address - Country:US
Mailing Address - Phone:917-862-6047
Mailing Address - Fax:
Practice Address - Street 1:2645 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-275-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-28
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036145576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty