Healthcare Provider Details

I. General information

NPI: 1366946246
Provider Name (Legal Business Name): ADAM GREGORY PORT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 OBETZ RD
COLUMBUS OH
43207-4036
US

IV. Provider business mailing address

651 RIVERVIEW DR APT 3
COLUMBUS OH
43202-1667
US

V. Phone/Fax

Practice location:
  • Phone: 614-409-1400
  • Fax:
Mailing address:
  • Phone: 614-581-9620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.442721
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: