Provider Demographics
NPI:1871555342
Name:PORTER, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:PORTER
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 1:240 MOUNT LEBANON BLVD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15234-1243
Mailing Address - Country:US
Mailing Address - Phone:412-561-7541
Mailing Address - Fax:412-561-2366
Practice Address - Street 1:240 MOUNT LEBANON BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15234-1243
Practice Address - Country:US
Practice Address - Phone:412-561-7541
Practice Address - Fax:412-561-2366
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-072074-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001830189Medicaid
PA04720Medicare ID - Type Unspecified
PA001830189Medicaid