1508940230 NPI number — MS. PAM A PORTER PT

Table of content: MS. PAM A PORTER PT (NPI 1508940230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508940230 NPI number — MS. PAM A PORTER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
PAM
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1508940230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTROSE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36559-0183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-621-6865
Provider Business Mailing Address Fax Number:
251-621-6891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAPHNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36526-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-621-6865
Provider Business Practice Location Address Fax Number:
251-621-6891
Provider Enumeration Date:
10/25/2006

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: 2251X0800X , with the licence number:  PTH1459 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51033114 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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