Healthcare Provider Details

I. General information

NPI: 1588079305
Provider Name (Legal Business Name): SAMUEL GRANT PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W FRONTIER LN
OLATHE KS
66061
US

IV. Provider business mailing address

961 E SHALIMAR DR
COLUMBIA MO
65202-1093
US

V. Phone/Fax

Practice location:
  • Phone: 913-397-7800
  • Fax:
Mailing address:
  • Phone: 309-202-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-38118
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: