Individual
FULTON PORTER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
17850 KEDZIE AVE, 3200, HAZEL CREST, IL 60429-2058
(708) 798-8112
(708) 798-9016
Mailing address
PO BOX 967, TINLEY PARK, IL 60477-0967
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036101229
IL
208M00000X
Hospitalist Physician
01071861A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036101229
—
IL
01
—
P00439469/CK6882
RAILROAD MEDICARE
IL
Enumeration date
07/05/2005
Last updated
12/12/2022
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