Basic Information
| Provider Information | |||||||||
| NPI: | 1720034226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 REDBUD DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153251206 | ||||||||
| FaxNumber: | 6153251245 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 REDBUD DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153251206 | ||||||||
| FaxNumber: | 6153251245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | RYDBURG | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6153737415 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HTI HOSPITAL HOLDINGS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3734188 | 05 | TN | MEDICAID |