Healthcare Provider Details

I. General information

NPI: 1578773032
Provider Name (Legal Business Name): BRENTON LYNN HARRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

2350 TIMBER CREEK DR
MARION IA
52302-9154
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3000
  • Fax:
Mailing address:
  • Phone: 319-594-6909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number103216
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01095516A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD29130
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36394
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: