=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255224861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM H HARRIS SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2025
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6544 S EBERHART AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-701-3227
-----------------------------------------------------
Fax | 708-606-8037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5463 YALE LN
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-701-3227
-----------------------------------------------------
Fax | 708-606-8037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | DW46643
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------