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General NPI Number Information
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NPI Number | 1063085629
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Entity Type | Individual
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Provider Name | MR. BERNARD DAVID PORTER
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Gender | Male
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Dates
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Enumeration Date | 07/21/2021
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Last Update Date | 07/21/2021
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Provider Practice Location Address
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Address Line | 18100 MEYERS RD
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City | DETROIT
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State | MI
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Zip | 48235-1426
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Country | US
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Telephone | 321-262-6700
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Fax |
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Provider Business Mailing Address
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Address Line | 17534 BIRCHCREST DR
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City | DETROIT
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State | MI
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Zip | 48221-2735
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Country | US
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Telephone | 989-274-2545
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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