Provider Demographics
NPI:1699742015
Name:HARRISON, MATTHEW WARREN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WARREN
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7950 N SHADELAND AVE
Practice Address - Street 2:STE 350
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-578-2600
Practice Address - Fax:317-578-6474
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051075A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200307760AMedicaid
IN000000793519OtherANTHEM
INP01170509OtherRR MEDICARE PTAN
H27233Medicare UPIN
IN200307760AMedicaid
INP01170509OtherRR MEDICARE PTAN