Basic Information
Provider Information | |||||||||
NPI: | 1134341746 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PORTERA MANKINS | ||||||||
FirstName: | SALLY | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PORTERA | ||||||||
OtherFirstName: | SALLY | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6186415410 | ||||||||
Practice Location | |||||||||
Address1: | 211 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622201915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6186415410 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 12/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 36117761 | IL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 2009023911 | MO | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.