Healthcare Provider Details

I. General information

NPI: 1649221508
Provider Name (Legal Business Name): STEPHEN D HARRISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 16TH AVE
FULTON IL
61252-9708
US

IV. Provider business mailing address

915 13TH AVE N
CLINTON IA
52732-5067
US

V. Phone/Fax

Practice location:
  • Phone: 815-589-2121
  • Fax: 815-589-4468
Mailing address:
  • Phone: 563-243-2511
  • Fax: 563-243-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24271
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: