Provider Demographics
NPI:1538134556
Name:PORTER, MICHAEL T (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:PORTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 W OAKTON
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1820
Mailing Address - Country:US
Mailing Address - Phone:847-692-6956
Mailing Address - Fax:847-692-9651
Practice Address - Street 1:2104 W OAKTON
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1820
Practice Address - Country:US
Practice Address - Phone:847-692-6956
Practice Address - Fax:847-692-9651
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL678090Medicare ID - Type Unspecified
ILT37754Medicare UPIN