Basic Information
| Provider Information | |||||||||
| NPI: | 1154758167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTAGE PHYSICIAN PRACTICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 9TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE LINDEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499451100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831030 | ||||||||
| FaxNumber: | 9062960521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.