Provider Demographics
NPI:1104869858
Name:HARRISON, ROBERT JR
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HARRISON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36M BADER LANE
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832
Mailing Address - Country:US
Mailing Address - Phone:401-364-1950
Mailing Address - Fax:401-364-1902
Practice Address - Street 1:25 WELLS STREET
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891
Practice Address - Country:US
Practice Address - Phone:401-364-1950
Practice Address - Fax:401-364-1902
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06502208600000X
CT25961208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D87205Medicare UPIN