Healthcare Provider Details

I. General information

NPI: 1912160441
Provider Name (Legal Business Name): RYAN G PORTER SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 FIELDS SOUTH DR
CHAMPAIGN IL
61822-3743
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-902-3277
  • Fax: 217-902-7757
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036129856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: