Provider Demographics
NPI:1972694685
Name:HARRIS, ANGIE MILLS (DO)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:MILLS
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR STE 260
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5363
Mailing Address - Country:US
Mailing Address - Phone:618-257-4100
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR STE 260
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5363
Practice Address - Country:US
Practice Address - Phone:618-257-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059470207Q00000X
IL036139138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7843Medicare PIN
GAH84732Medicare UPIN
GA200864966AMedicaid