Provider Demographics
NPI:1366946246
Name:PORT, ADAM GREGORY (RN)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:GREGORY
Last Name:PORT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 RIVERVIEW DR APT 3
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1667
Mailing Address - Country:US
Mailing Address - Phone:614-581-9620
Mailing Address - Fax:
Practice Address - Street 1:301 OBETZ RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4036
Practice Address - Country:US
Practice Address - Phone:614-409-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.442721163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse