Healthcare Provider Details

I. General information

NPI: 1598730152
Provider Name (Legal Business Name): CARSON R HARRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8040 OLD CEDAR AVE S STE 100
BLOOMINGTON MN
55425-1205
US

IV. Provider business mailing address

8100 34TH AVE S MC21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax: 651-254-5216
Mailing address:
  • Phone: 952-883-7172
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number31091
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number31091
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: