Healthcare Provider Details

I. General information

NPI: 1649228750
Provider Name (Legal Business Name): PHILLIP GORDON HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 S KING ST
WINDSOR NC
27983-9666
US

IV. Provider business mailing address

1403 S KING ST
WINDSOR NC
27983-9666
US

V. Phone/Fax

Practice location:
  • Phone: 252-794-6775
  • Fax: 252-794-6771
Mailing address:
  • Phone: 252-794-6775
  • Fax: 252-794-6771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34986
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: