Healthcare Provider Details

I. General information

NPI: 1750998464
Provider Name (Legal Business Name): MATTHEW PORCH RT(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2020
Last Update Date: 09/26/2020
Certification Date: 09/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

5245 ASHDOWN PLACE CV
SOUTHAVEN MS
38672-6060
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7100
  • Fax:
Mailing address:
  • Phone: 901-628-8263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: