Provider Demographics
NPI:1386271393
Name:PORTER, ELISE REBECCA (MD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:REBECCA
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:REBECCA
Other - Last Name:BRISCOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1130 W MICHIGAN ST # FH204
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-274-0076
Mailing Address - Fax:317-274-0256
Practice Address - Street 1:1130 W MICHIGAN ST # FH204
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-274-0076
Practice Address - Fax:317-274-0256
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01093005A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104197686OtherANTHEM PTAN