Basic Information
| Provider Information | |||||||||
| NPI: | 1437312915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTIS | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 971 LAKELAND DR | ||||||||
| Address2: | STE 1052 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6017143415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2008 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 21256 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 21256 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00809533 | 05 | MS | MEDICAID |