1720027535 NPI number — DR. EDNA KATHLEEN PORTER MD

Table of content: DR. EDNA KATHLEEN PORTER MD (NPI 1720027535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720027535 NPI number — DR. EDNA KATHLEEN PORTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
EDNA
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PORTER
Provider Other First Name:
EDNA
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720027535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 CONCORD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
251-470-5809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16261 BASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-481-5477
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2006

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: 207VM0101X , with the licence number:  12261 , 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: 51518817 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009978020 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51506877 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009936165 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009978010 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1147427 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51542411 . This is a "BCBS - 1707 CENTER ST., STE 102" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 74-00030 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51592379 . This is a "BCBS - 2451 FILLINGIM" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 00125124 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 046648400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51506879 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 160056309 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51544114 . This is a "BCBS - 1700 CENTER ST" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51594001 . This is a "BCBS - 150 S. INGLESIDE ST, STE 6" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 111671200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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