Provider Demographics
NPI:1316944341
Name:PORTER, FULTON III (MD)
Entity type:Individual
Prefix:
First Name:FULTON
Middle Name:
Last Name:PORTER
Suffix:III
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17850 KEDZIE AVE
Practice Address - Street 2:3200
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2058
Practice Address - Country:US
Practice Address - Phone:708-798-8112
Practice Address - Fax:708-798-9016
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071861A208M00000X
IL036101229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101229Medicaid
ILP00439469/CK6882OtherRAILROAD MEDICARE
IL203980/K45657Medicare PIN
IL497610/K08917Medicare ID - Type UnspecifiedGROUP#/ PROV#
ILP00439469/CK6882OtherRAILROAD MEDICARE