1376744664 NPI number — PORTER PHYSICIAN SERVICES LLC

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 1376744664 NPI number — PORTER PHYSICIAN SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTER PHYSICIAN SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PORTER OCCUPATIONAL MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376744664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46368-5528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-763-6858
Provider Business Mailing Address Fax Number:
219-763-4858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3220 LANCER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46368-4495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-764-8439
Provider Business Practice Location Address Fax Number:
219-764-8463
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEWSOME
Authorized Official First Name:
GARY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-465-7000

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com