1174783005 NPI number — MARY THERESE PORTA PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174783005 NPI number — MARY THERESE PORTA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTA
Provider First Name:
MARY
Provider Middle Name:
THERESE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN
Provider Other First Name:
MARY
Provider Other Middle Name:
THERESE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174783005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1865
Provider Business Mailing Address Fax Number:
947-522-0307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44201 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE EC
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-964-5111
Provider Business Practice Location Address Fax Number:
248-964-5068
Provider Enumeration Date:
06/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601005244 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110F376980 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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