Provider Demographics
NPI:1255301446
Name:PORCH, ELLIS F JR (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:F
Last Name:PORCH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1518 N BRINDLEE MOUNTAIN PKWY
Mailing Address - Street 2:PO BOX 710
Mailing Address - City:ARAB
Mailing Address - State:AL
Mailing Address - Zip Code:35016-5723
Mailing Address - Country:US
Mailing Address - Phone:256-586-1380
Mailing Address - Fax:256-586-8364
Practice Address - Street 1:1518 N BRINDLEE MOUNTAIN PKWY
Practice Address - Street 2:
Practice Address - City:ARAB
Practice Address - State:AL
Practice Address - Zip Code:35016-5723
Practice Address - Country:US
Practice Address - Phone:256-586-1380
Practice Address - Fax:256-586-8364
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC73913Medicare UPIN
ALD293Medicare ID - Type UnspecifiedALABAMA