Healthcare Provider Details

I. General information

NPI: 1457566309
Provider Name (Legal Business Name): PORTER PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

IV. Provider business mailing address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

V. Phone/Fax

Practice location:
  • Phone: 219-759-5791
  • Fax: 219-759-3807
Mailing address:
  • Phone: 219-759-5791
  • Fax: 219-759-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626