Healthcare Provider Details

I. General information

NPI: 1922090224
Provider Name (Legal Business Name): KEITH R. HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARKET PLACE BLVD STE 300
CARTERSVILLE GA
30121-8717
US

IV. Provider business mailing address

103 JOHN MADDOX DR NW
ROME GA
30165-1419
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-9600
  • Fax: 470-447-1815
Mailing address:
  • Phone: 706-235-7711
  • Fax: 706-235-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number050930
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number050930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: