Healthcare Provider Details

I. General information

NPI: 1598457368
Provider Name (Legal Business Name): BENJAMIN GARRETT HARSIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

2100 POWELL ST STE 410
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125081434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: