Basic Information
| Provider Information | |||||||||
| NPI: | 1689642357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 EAST WALNUT ST | ||||||||
| Address2: | PO BOX 760 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122547310 | ||||||||
| FaxNumber: | 8122578602 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 NORTH WEST STREET | ||||||||
| Address2: | |||||||||
| City: | ODON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126367300 | ||||||||
| FaxNumber: | 8126368204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01043657A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA5604 | 01 | IN | MEDICARE RAILROAD GROUP | OTHER | 000000305515 | 01 | IN | ANTHEM | OTHER | 200447610 | 05 | IN | MEDICAID | P00059849 | 01 | IN | MEDICARE RAILROAD | OTHER |