Healthcare Provider Details

I. General information

NPI: 1760495105
Provider Name (Legal Business Name): PORTER PEDIATRICS COMPREHENSIVE PEDIATRIC HEALTH CARE.PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 TREMONT ST
BOSTON MA
02116-5538
US

IV. Provider business mailing address

354 TREMONT ST
BOSTON MA
02116-5538
US

V. Phone/Fax

Practice location:
  • Phone: 617-426-9200
  • Fax: 617-426-9201
Mailing address:
  • Phone: 617-426-9200
  • Fax: 617-426-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number80061
License Number StateMA

VIII. Authorized Official

Name: LYNN S PORTER
Title or Position: PRESIDENT
Credential: M.D
Phone: 617-426-9200