Healthcare Provider Details

I. General information

NPI: 1841533171
Provider Name (Legal Business Name): KAMI JO LARSON HARLESS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAMI JO LARSON

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-757-8161
Mailing address:
  • Phone: 217-545-8000
  • Fax: 844-470-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60587321
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036.142057
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.142057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: