Healthcare Provider Details

I. General information

NPI: 1346982162
Provider Name (Legal Business Name): BRIAN WILLIAM PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N YORK ST
ELMHURST IL
60126-2377
US

IV. Provider business mailing address

300 N YORK ST
ELMHURST IL
60126-2377
US

V. Phone/Fax

Practice location:
  • Phone: 888-584-7888
  • Fax: 630-833-8834
Mailing address:
  • Phone: 888-584-7888
  • Fax: 630-833-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.178282
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number74217
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74217
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.178282
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: