Basic Information
| Provider Information | |||||||||
| NPI: | 1811993793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 ARCH ST | ||||||||
| Address2: | STE 150 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305640728 | ||||||||
| FaxNumber: | 3305640733 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 ARCH ST | ||||||||
| Address2: | STE 150 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305640728 | ||||||||
| FaxNumber: | 3305640733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 174400000X | 35048232O | OH | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000000029383 | 01 | OH | ANTHEM BC BS | OTHER | 0681525 | 05 | OH | MEDICAID |