Provider Demographics
NPI:1235162850
Name:PORTNER MEDICAL PC
Entity Type:Organization
Organization Name:PORTNER MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-266-3050
Mailing Address - Street 1:1783 SHELL RING CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8030
Mailing Address - Country:US
Mailing Address - Phone:310-266-3050
Mailing Address - Fax:310-454-5318
Practice Address - Street 1:1783 SHELL RING CIR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8030
Practice Address - Country:US
Practice Address - Phone:310-266-3050
Practice Address - Fax:310-454-5318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28757207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMD87328OtherSTATE OF SOUTH CAROLINA
CAA87293Medicare UPIN