Basic Information
| Provider Information | |||||||||
| NPI: | 1114934031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORT | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169751845 | ||||||||
| FaxNumber: | 6162850846 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 FELCH ST | ||||||||
| Address2: | |||||||||
| City: | ZEELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494642608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167724644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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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 | 207PE0004X | 4301080313 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207L00000X | 4301080313 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00280900 | 01 | MI | RAILROAD MEDICARE | OTHER |