Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207L00000X | Anesthesiologist | 4301080313 | MI |
Y | 207PE0004X | Emergency Medical Services | 4301080313 | MI |
NPI | 1114934031 |
---|---|
Provider Name | Christopher B Port |
First Address | Chicago, IL 60689-5325 |
Second Address | Zeeland, MI 49464-2608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2006 |
Last Update Date | 27/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I16650 | (02) | MI |
P00280900 | RAILROAD MEDICARE (01) | MI |