Provider Demographics
NPI:1346232634
Name:PORTER, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S HERLONG AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1182
Mailing Address - Country:US
Mailing Address - Phone:803-366-6135
Mailing Address - Fax:803-366-3439
Practice Address - Street 1:200 S HERLONG AVE
Practice Address - Street 2:SUITE H
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-366-6135
Practice Address - Fax:803-366-3439
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC225002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA8722Medicaid
NC7902900Medicaid
NC1125Medicare PIN
NCC02626Medicare UPIN
NC7902900Medicaid
SC2435Medicare PIN