MEDICARE: DR. ELLIS F PORCH JR. M.D.

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	207R00000X	Internal Medicine Physician	12159	AL

General Provider Information

NPI Number	:	1255301446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLIS F PORCH JR. M.D.

Provider Business Mailing Address
First Line	:	1518 N BRINDLEE MOUNTAIN PKWY
Second Line	:	PO BOX 710
City	:	ARAB
State	:	AL
Zip	:	35016-5723
Country	:	US
Telephone Number	:	256-586-1380
Fax Number	:	256-586-8364

Provider Business Practice Location Address
First Line	:	1518 N BRINDLEE MOUNTAIN PKWY
Second Line	:
City	:	ARAB
State	:	AL
Zip	:	35016-5723
Country	:	US
Telephone Number	:	256-586-1380
Fax Number	:	256-586-8364

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	07/09/2007

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