Provider Demographics
NPI:1366469108
Name:PORTEE, SIMON E (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:E
Last Name:PORTEE
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 1:5968 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6055
Mailing Address - Country:US
Mailing Address - Phone:678-476-1448
Mailing Address - Fax:
Practice Address - Street 1:120 SILOAM ROAD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642
Practice Address - Country:US
Practice Address - Phone:706-453-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033177207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E91630Medicare UPIN