Provider Demographics
NPI:1114912920
Name:PORTER, GLYN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:GLYN
Middle Name:ANNE
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 PEPPER CREEK BRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-7127
Mailing Address - Country:US
Mailing Address - Phone:219-405-9950
Mailing Address - Fax:219-464-3873
Practice Address - Street 1:2901 PEPPER CREEK BRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-7127
Practice Address - Country:US
Practice Address - Phone:219-405-9950
Practice Address - Fax:219-464-3873
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044317A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200409510Medicaid
IN200409510Medicaid
IN199830IMedicare PIN
G80111Medicare UPIN
IN199060LMedicare PIN
IN200550IMedicare PIN