Provider Demographics
NPI:1689642258
Name:PORTER, MARY J (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 14417
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1417
Mailing Address - Country:US
Mailing Address - Phone:912-629-2290
Mailing Address - Fax:912-629-2291
Practice Address - Street 1:340 HODGSON CT
Practice Address - Street 2:SUITE #2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1520
Practice Address - Country:US
Practice Address - Phone:912-629-2290
Practice Address - Fax:912-629-2291
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA032635207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000473833FMedicaid
GA290011257OtherRAILROAD MEDICARE
GAE60737Medicare UPIN
GA000473833FMedicaid