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1194798819

NPI Code Detail

MEDICARE: DR. BURDETT ROY PORTER M.D.

MEDICARE: DR. BURDETT ROY PORTER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	217587-1	NY
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	217587-1	NY
3	207LP2900X	Pain Medicine (Anesthesiology) Physician	MD042659L	PA
4	2083C0008X	Clinical Informatics Physician	MD042659L	PA
5	208VP0014X	Interventional Pain Medicine Physician	217587-1	NY
6	208VP0014X	Interventional Pain Medicine Physician	MD042659L	PA
7	207L00000X	Anesthesiology Physician	MD042659L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CC9269	OTHER	PA	RR MEDICARE GROUP
4	GU039832	OTHER	OK	PA MEDICARE GROUP
5	050075753	OTHER	PA	RR MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194798819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BURDETT ROY PORTER M.D.

Provider Business Mailing Address
First Line	:	1 GUTHRIE SQ
Second Line	:
City	:	SAYRE
State	:	PA
Zip	:	18840-1625
Country	:	US
Telephone Number	:	570-888-5858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 GUTHRIE SQ
Second Line	:
City	:	SAYRE
State	:	PA
Zip	:	18840-1625
Country	:	US
Telephone Number	:	570-887-6133
Fax Number	:	570-887-4464

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	03/01/2021

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Directions to “ DR. BURDETT ROY PORTER M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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