Basic Information
| Provider Information | |||||||||
| NPI: | 1346256583 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PORTER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N 20TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191031443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155672422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 02/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD064565L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0402X | MD064565L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0400X | G89267 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0402X | G89267 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001910252 | 05 | PA | MEDICAID | 8904502 | 05 | NJ | MEDICAID |