Healthcare Provider Details

I. General information

NPI: 1316944341
Provider Name (Legal Business Name): FULTON PORTER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17850 KEDZIE AVE 3200
HAZEL CREST IL
60429-2058
US

IV. Provider business mailing address

PO BOX 967
TINLEY PARK IL
60477-0967
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-8112
  • Fax: 708-798-9016
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01071861A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036101229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: