Provider Demographics
NPI:1497296743
Name:PORTER, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9430
Mailing Address - Country:US
Mailing Address - Phone:317-332-9861
Mailing Address - Fax:317-893-4453
Practice Address - Street 1:601 RICHMOND RD N
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-8788
Practice Address - Country:US
Practice Address - Phone:859-986-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-19
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012352A225100000X
KY006907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist