Healthcare Provider Details

I. General information

NPI: 1710890736
Provider Name (Legal Business Name): AIDAN JAMES PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 LAKE LAND BLVD
MATTOON IL
61938-5283
US

IV. Provider business mailing address

501 LAKE LAND BLVD
MATTOON IL
61938-5283
US

V. Phone/Fax

Practice location:
  • Phone: 217-235-8100
  • Fax:
Mailing address:
  • Phone: 217-235-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150116398
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: