MEDICARE: MARCUS PORTER RN

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	163WH0200X	Home Health Registered Nurse	4704294821	MI

General Provider Information

NPI Number	:	1811364904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS PORTER RN

Provider Business Mailing Address
First Line	:	11734 LANSDOWNE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48224-1699
Country	:	US
Telephone Number	:	248-440-1488
Fax Number	:

Provider Business Practice Location Address
First Line	:	28000 WOODWARD AVE
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-0960
Country	:	US
Telephone Number	:	248-440-1488
Fax Number	:

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

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	08/25/2015

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