Provider Demographics
NPI:1588871875
Name:HARRIS, MARIEL ANN (MD)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:ANN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 EUCLID AVE
Mailing Address - Street 2:MAILSTOP HAN 6095
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-464-6453
Mailing Address - Fax:216-464-6403
Practice Address - Street 1:ONE DAVID N MYERS PARKWAY
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-910-2641
Practice Address - Fax:216-910-2777
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33055569207R00000X
OH35-055569207QG0300X
CT22992207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH414975OtherWELLCARE #
OH4320316OtherAETNA #
OH0679663Medicaid
OH751150OtherBUCKEYE #
OHP00432289OtherRAILROAD MEDICARE
OH000000537785OtherANTHEM #
OH000000225049OtherUNISON #
OH751150OtherBUCKEYE #
OHC03263Medicare UPIN
OHMA0604742Medicare ID - Type Unspecified