Healthcare Provider Details

I. General information

NPI: 1326895897
Provider Name (Legal Business Name): MARSHALL LOGAN PORRITT HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5383 EHRLICH RD STE 104
TAMPA FL
33625-5529
US

IV. Provider business mailing address

5383 EHRLICH RD STE 104
TAMPA FL
33625-5529
US

V. Phone/Fax

Practice location:
  • Phone: 813-269-2500
  • Fax:
Mailing address:
  • Phone: 813-269-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: