Provider Demographics
NPI:1851735302
Name:THEODORE B PORTER, DO, PC
Entity Type:Organization
Organization Name:THEODORE B PORTER, DO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARUIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-639-2555
Mailing Address - Street 1:1413 W MOYAMENSING AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4625
Mailing Address - Country:US
Mailing Address - Phone:267-639-2555
Mailing Address - Fax:267-639-2632
Practice Address - Street 1:1413 W MOYAMENSING AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4625
Practice Address - Country:US
Practice Address - Phone:267-639-2555
Practice Address - Fax:267-639-2632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003735L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D98662Medicare UPIN