Basic Information
| Provider Information | |||||||||
| NPI: | 1821128968 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTAGE HEALTH INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 894 CAMPUS DR | ||||||||
| Address2: | STE B | ||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499301571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831128 | ||||||||
| FaxNumber: | 9064831122 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CAMPUS DR, | ||||||||
| Address2: | |||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499301569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831045 | ||||||||
| FaxNumber: | 9064831044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | GODAMSKI | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9064831045 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PORTAGE HEALTH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 310020 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0C16002 | 01 | MI | MEDICARE GROUP | OTHER | 700C16002 | 01 | MI | BCBSM | OTHER |