Provider Demographics
NPI:1194798819
Name:PORTER, BURDETT ROY (MD)
Entity type:Individual
Prefix:DR
First Name:BURDETT
Middle Name:ROY
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-887-6133
Practice Address - Fax:570-887-4464
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217587-1207L00000X, 207LP2900X, 208VP0014X
PAMD042659L207LP2900X, 2083C0008X, 208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017472240001Medicaid
NY01950201Medicaid
PACC9269OtherRR MEDICARE GROUP
OKGU039832OtherPA MEDICARE GROUP
PA050075753OtherRR MEDICARE PIN
PA050075753OtherRR MEDICARE PIN
PA026208N8ZMedicare ID - Type Unspecified