Provider Demographics
NPI:1780722660
Name:BRACKIN PORTER FAMILY MEDICINE
Entity type:Organization
Organization Name:BRACKIN PORTER FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-880-9333
Mailing Address - Street 1:1080 POLARIS PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-6035
Mailing Address - Country:US
Mailing Address - Phone:614-880-9333
Mailing Address - Fax:614-880-9331
Practice Address - Street 1:1080 POLARIS PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-6035
Practice Address - Country:US
Practice Address - Phone:614-880-9333
Practice Address - Fax:614-880-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care