Healthcare Provider Details

I. General information

NPI: 1073514238
Provider Name (Legal Business Name): KEVIN CHARLES HARRISON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9460 AMBERDALE DRIVE SUITE C
RICHMOND VA
23236
US

IV. Provider business mailing address

9460 AMBERDALE DRIVE SUITE C
RICHMOND VA
23236
US

V. Phone/Fax

Practice location:
  • Phone: 804-276-2470
  • Fax: 804-276-2473
Mailing address:
  • Phone: 804-276-2470
  • Fax: 804-276-2473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102201098
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: