Provider Demographics
NPI:1154952505
Name:MODERN PEDIATRICS PROFESSIONALS, PLLC
Entity type:Organization
Organization Name:MODERN PEDIATRICS PROFESSIONALS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-541-7604
Mailing Address - Street 1:2309 SANTA MARIA ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4617
Mailing Address - Country:US
Mailing Address - Phone:319-541-7604
Mailing Address - Fax:
Practice Address - Street 1:2309 SANTA MARIA ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4617
Practice Address - Country:US
Practice Address - Phone:319-541-7604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty