Healthcare Provider Details

I. General information

NPI: 1063805240
Provider Name (Legal Business Name): MARK ORSON HARRIS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15476A DEDEAUX RD
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

106 OAKS BLVD
BAY ST LOUIS MS
39520-3016
US

V. Phone/Fax

Practice location:
  • Phone: 228-539-3232
  • Fax:
Mailing address:
  • Phone: 228-216-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT3297
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: