Basic Information
| Provider Information | |||||||||
| NPI: | 1598886616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND MEDICAL CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 716 DELAWARE AVENUE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183510358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708976272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 716 DELAWARE AVENUE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183510358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708976272 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DECESARE | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5708976272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | OS002690L | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 548961 | 01 | US HEALTHCARE | OTHER | DE 041920 | 01 | PA BLUE SHIELD | OTHER | 14843 | 01 | GEISENGERS HEALTH CARE | OTHER | 001706 | 01 | PA | FIRST PRIORITY | OTHER |