Provider Demographics
NPI:1598765471
Name:PORT, STEVEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:C
Last Name:PORT
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:PO BOX 2040
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2040
Mailing Address - Country:US
Mailing Address - Phone:414-649-3530
Mailing Address - Fax:414-649-3551
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:#840
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-3530
Practice Address - Fax:414-649-3551
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25008207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30488300Medicaid
WI002160350Medicare PIN
WIB55803Medicare UPIN
WI002104130Medicare PIN
WI002146515Medicare PIN
WI002140245Medicare PIN
WI30488300Medicaid