Provider Demographics
NPI:1588678155
Name:PORTER, PAUL T (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:19229 MACK AVE STE 24
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2857
Mailing Address - Country:US
Mailing Address - Phone:313-884-5522
Mailing Address - Fax:313-884-5521
Practice Address - Street 1:19229 MACK AVE STE 24
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2857
Practice Address - Country:US
Practice Address - Phone:313-884-5522
Practice Address - Fax:313-884-5521
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPP049599207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4207010Medicaid
MI4207000Medicaid
MI0829220OtherBCN
MI0829220OtherBCN