Healthcare Provider Details

I. General information

NPI: 1477521094
Provider Name (Legal Business Name): CLINTON J HARRIS, MD, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 E FULTON ST
GRAND RAPIDS MI
49546-1322
US

IV. Provider business mailing address

3600 E FULTON
GRAND RAPIDS MI
49546-1322
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4971
  • Fax: 616-248-3530
Mailing address:
  • Phone: 616-949-4971
  • Fax: 616-248-3530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLINTON JACOB HARRIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 616-949-4971