Provider Demographics
NPI:1588648497
Name:PORTS, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:PORTS
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 1:450 ALKYRE RUN
Mailing Address - Street 2:SUITE 380
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-6909
Mailing Address - Country:US
Mailing Address - Phone:614-899-9188
Mailing Address - Fax:614-899-9198
Practice Address - Street 1:450 ALKYRE RUN
Practice Address - Street 2:SUITE 380
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-6909
Practice Address - Country:US
Practice Address - Phone:614-899-9188
Practice Address - Fax:614-899-9198
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-8582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0366205Medicaid
OH0366205Medicaid
OH0448915Medicare PIN