=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588871875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIEL ANN HARRIS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 01/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ONE DAVID N MYERS PARKWAY
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-910-2641
-----------------------------------------------------
Fax | 216-910-2777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11100 EUCLID AVE MAILSTOP HAN 6095
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-464-6453
-----------------------------------------------------
Fax | 216-464-6403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 33055569
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 35-055569
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 22992
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------