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General NPI Number Information
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NPI Number | 1457566309
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Entity Type | Organization
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Legal Business Name | PORTER PHYSICIAN SERVICES LLC
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 01/28/2009
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Provider Practice Location Address
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Address Line | 3630 WILLOWCREEK RD
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City | PORTAGE
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State | IN
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Zip | 46368-5075
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Country | US
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Telephone | 219-759-5791
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Fax | 219-759-3807
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Provider Business Mailing Address
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Address Line | 3630 WILLOWCREEK RD
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City | PORTAGE
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State | IN
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Zip | 46368-5075
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Country | US
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Telephone | 219-759-5791
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Fax | 219-759-3807
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Authorized Official
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Title or Position | DIRECTOR OF PROVIDER ENROLLMENT
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Name | DEBBIE T BREWER
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Credential |
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Telephone | 615-465-7626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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