Healthcare Provider Details

I. General information

NPI: 1962029579
Provider Name (Legal Business Name): NEELY TAYLOR ROSE HARRIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

230 N 2625 EAST RD
PANA IL
62557-6642
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020018778
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-166678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: