Provider Demographics
NPI:1114949393
Name:PORTER, CHARLES B (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CAMBRIDGE ST STE G600
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8501
Mailing Address - Country:US
Mailing Address - Phone:913-588-9600
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST STE G600
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8500
Practice Address - Country:US
Practice Address - Phone:913-588-9600
Practice Address - Fax:913-588-9770
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17907207RC0000X
MOR7C72207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS051569OtherBCBS KS
KS100202670BMedicaid
MO202205704Medicaid
10338011OtherBCBS KC
KS100202670AMedicaid
10338011OtherBCBS KC
C50778Medicare UPIN
MO202205704Medicaid
KS051569OtherBCBS KS
KS060062389Medicare PIN
KS051569Medicare PIN
KS0386380BMedicare PIN