Provider Demographics
NPI:1821036179
Name:PORTER, KEITH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:423-224-3258
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN35985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3870838Medicaid
TN3870838Medicaid
TN3870838Medicare PIN
G63286Medicare UPIN