Healthcare Provider Details

I. General information

NPI: 1245340223
Provider Name (Legal Business Name): CHARLES R HARRISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MICHIGAN ST NE STE 6300
GRAND RAPIDS MI
49503-2562
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-6000
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberCH070071
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: