=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285696112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY L. HARRIS, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 11/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 371 PEACHTREE ST
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31545-0245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-530-7301
-----------------------------------------------------
Fax | 912-530-7302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 604
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31598-0604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-530-7301
-----------------------------------------------------
Fax | 912-530-7302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ANTONIA BROOKE HARRIS
-----------------------------------------------------
Credential | CSW
-----------------------------------------------------
Telephone | 912-530-7301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 024255
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 024255
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------