Healthcare Provider Details

I. General information

NPI: 1114783149
Provider Name (Legal Business Name): ROBERT SAMUEL PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MILLETT DR
AUBURN ME
04210-4055
US

IV. Provider business mailing address

2 SPRING ST
MECHANIC FALLS ME
04256-6170
US

V. Phone/Fax

Practice location:
  • Phone: 207-783-0018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT838
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: