Provider Demographics
NPI:1376744664
Name:PORTER PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:PORTER PHYSICIAN SERVICES LLC
Other - Org Name:PORTER OCCUPATIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:PO BOX 2028
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5528
Mailing Address - Country:US
Mailing Address - Phone:219-763-6858
Mailing Address - Fax:219-763-4858
Practice Address - Street 1:3220 LANCER ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4495
Practice Address - Country:US
Practice Address - Phone:219-764-8439
Practice Address - Fax:219-764-8463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherEMPLOYER TAX ID