MEDICARE: SPORTERDO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	288579 1204	UT

General Provider Information

NPI Number	:	1023344272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTERDO LLC

Provider Business Mailing Address
First Line	:	3650 N UNIVERSITY AVE
Second Line	:	SUITE 200
City	:	PROVO
State	:	UT
Zip	:	84604-6656
Country	:	US
Telephone Number	:	801-375-7100
Fax Number	:	801-375-7102

Provider Business Practice Location Address
First Line	:	3650 N UNIVERSITY AVE
Second Line	:	SUITE 200
City	:	PROVO
State	:	UT
Zip	:	84604-6656
Country	:	US
Telephone Number	:	801-375-7100
Fax Number	:	801-375-7102

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. STUART PORTER
Credential	:	D.O.
Telephone Number	:	801-375-7100

Provider Enumeration Date	:	10/22/2009
Last Update Date	:	10/22/2009

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3650 N UNIVERSITY AVE , SUITE 200
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Practice Location Address:

3650 N UNIVERSITY AVE , #200
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Directions to “SPORTERDO LLC ” Practice Location

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