Provider Demographics
NPI:1205114808
Name:PORTER, ELIZABETH-CLARE MCCULLOCH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH-CLARE
Middle Name:MCCULLOCH
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH-CLARE
Other - Middle Name:MCCULLOCH
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:3555 HARDEN STREET EXT STE 141
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6894
Practice Address - Country:US
Practice Address - Phone:803-434-4300
Practice Address - Fax:803-434-4351
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-30
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD378722084P0800X
CAA1226832084P0800X
SC378722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC378727Medicaid