1518900802 NPI number — RONALD D PORTER CRNA

Table of content: RONALD D PORTER CRNA (NPI 1518900802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518900802 NPI number — RONALD D PORTER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
RONALD
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

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:
1518900802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 STANAFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BECKLEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25801-3142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-255-3436
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-9006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-342-1610
Provider Business Practice Location Address Fax Number:
681-342-1626
Provider Enumeration Date:
06/14/2006

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: 367500000X , with the licence number:  21431 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001706470 . This is a "MSBCBS GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810006746 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF0767 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 205542387 . This is a "AAP TRI CARE NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 27005299700 . This is a "TRICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 270052997004 . This is a "TRICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 270052997004 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0067342000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8226335 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1054827 . This is a "WORKERS COMP INDIVIDUAL" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00211135 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001713627 . This is a "BCBS AAP NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001713627 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001907661 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0207026000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27005299701 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: DA0096 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00407274 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 20554238700 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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