MEDICARE: WALTER FRANK PORTER III MPT

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	52806653017	OTHER	GA	BCBS GA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	52806653006	OTHER	GA	BCBS GA

General Provider Information

NPI Number	:	1710933924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER FRANK PORTER III MPT

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 1200, SUITES 100 & 110
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	770-926-2744
Fax Number	:	770-926-2794

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	02/04/2011

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