Provider Demographics
NPI:1255303236
Name:PORTER UMPHREY, ALYX B (MD)
Entity Type:Individual
Prefix:
First Name:ALYX
Middle Name:B
Last Name:PORTER UMPHREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALYX
Other - Middle Name:B
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5404
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN468282084N0402X
AZ405462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ348485Medicaid
AZP00625173OtherRAILROAD MEDICARE
MN993143100Medicaid
AZP00625173OtherRAILROAD MEDICARE
AZ348485Medicaid
AZZ123063Medicare PIN