Provider Demographics
NPI:1649476169
Name:MICHAEL L. HARRIS MD, LTD
Entity type:Organization
Organization Name:MICHAEL L. HARRIS MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LINDON
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-766-6266
Mailing Address - Street 1:4501 MACCORKLE AVE SW
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-766-6266
Mailing Address - Fax:304-766-7825
Practice Address - Street 1:4501 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 500
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-766-6266
Practice Address - Fax:304-766-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17469332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0095821001Medicaid
WV0095821001Medicaid