Provider Demographics
NPI:1043286313
Name:PORUBSKY, EDWARD A (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:PORUBSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 N BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3000
Mailing Address - Country:US
Mailing Address - Phone:706-868-5676
Mailing Address - Fax:706-722-2824
Practice Address - Street 1:340 N BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3000
Practice Address - Country:US
Practice Address - Phone:706-868-5676
Practice Address - Fax:706-722-2824
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053019207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA952703OtherBLUE CROSS
157315300OtherEMPLOYMENT STANDARD WORK
4305494OtherAETNA
3285145OtherCIGNA
GA519526707AMedicaid
GAP00177360OtherMEDICARE RAILROAD
GA952703OtherBLUE CROSS
GA04BDCNTMedicare ID - Type Unspecified