Basic Information
| Provider Information | |||||||||
| NPI: | 1689642258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14417 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314161417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126292290 | ||||||||
| FaxNumber: | 9126292291 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 HODGSON CT | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314061520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126292290 | ||||||||
| FaxNumber: | 9126292291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 032635 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 032635 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000473833F | 05 | GA | MEDICAID | 290011257 | 01 | GA | RAILROAD MEDICARE | OTHER |