Provider Demographics
NPI:1558544890
Name:PORTMAN, EDWARD
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:PORTMAN
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 1:1280 W PEACHTREE ST NW
Mailing Address - Street 2:SUITE 131
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3445
Mailing Address - Country:US
Mailing Address - Phone:404-876-4001
Mailing Address - Fax:
Practice Address - Street 1:1280 W PEACHTREE ST NW
Practice Address - Street 2:SUITE 131
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3445
Practice Address - Country:US
Practice Address - Phone:404-876-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016660207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG85000424Medicare UPIN