Basic Information
| Provider Information | |||||||||
| NPI: | 1114949393 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 CAMBRIDGE ST STE G600 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 CAMBRIDGE ST STE G600 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889600 | ||||||||
| FaxNumber: | 9135889770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 04-17907 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | R7C72 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 051569 | 01 | KS | BCBS KS | OTHER | 100202670B | 05 | KS | MEDICAID | 202205704 | 05 | MO | MEDICAID | 10338011 | 01 | BCBS KC | OTHER | 100202670A | 05 | KS | MEDICAID |