=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528100948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM W HARLESS M.D. PHD.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 12/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3415 MACCORKLE AVE SE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-388-4949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 AFFLINK PL STE 101
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35406-2289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-366-9740
-----------------------------------------------------
Fax | 205-344-9992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 37144
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | MD23392
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 62961
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 21423
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------