MEDICARE: DR. GLENN D HARRIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0203X	Pediatric Critical Care Medicine Physician	34620	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	370015146	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	39894	OTHER	NC	BCBS NC

General Provider Information

NPI Number	:	1194717736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN D HARRIS MD

Provider Business Mailing Address
First Line	:	PO BOX 751069
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1069
Country	:	US
Telephone Number	:	252-744-3253
Fax Number	:	252-744-3194

Provider Business Practice Location Address
First Line	:	2150 HERBERT CT
Second Line	:	ECU PHYSICIANS PEDIATRIC SPECIALTY CARE CLINIC
City	:	GREENVILLE
State	:	NC
Zip	:	27834-3736
Country	:	US
Telephone Number	:	252-744-5437
Fax Number	:	252-744-1514

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	11/29/2011

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