Provider Demographics
NPI:1053500801
Name:THOMAS N PORTER MD SC
Entity Type:Organization
Organization Name:THOMAS N PORTER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-367-1151
Mailing Address - Street 1:755 S MILWAUKEE AVE
Mailing Address - Street 2:STE 263
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3266
Mailing Address - Country:US
Mailing Address - Phone:847-367-1151
Mailing Address - Fax:847-367-8729
Practice Address - Street 1:755 S MILWAUKEE AVE
Practice Address - Street 2:STE 263
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3266
Practice Address - Country:US
Practice Address - Phone:847-367-1151
Practice Address - Fax:847-367-8729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04915342OtherBLUE CROSS BLUE SHIELD
IL04915342OtherBLUE CROSS BLUE SHIELD