Healthcare Provider Details

I. General information

NPI: 1336133602
Provider Name (Legal Business Name): BRIAN R PORT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12801 IRON BRIDGE RD SUITE 200
CHESTER VA
23831-1669
US

IV. Provider business mailing address

12801 IRON BRIDGE RD SUITE 200
CHESTER VA
23831-1669
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-9071
  • Fax: 804-768-8626
Mailing address:
  • Phone: 804-748-9071
  • Fax: 804-768-8626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101-033236
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101033236
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: