Provider Demographics
NPI:1447095526
Name:HARRIS, MICHAEL TODD (SRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E FORT AVE APT 739
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5508
Mailing Address - Country:US
Mailing Address - Phone:304-612-3611
Mailing Address - Fax:
Practice Address - Street 1:655 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1512
Practice Address - Country:US
Practice Address - Phone:410-706-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR262094163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse