Provider Demographics
NPI:1083767677
Name:PORTAGE FAMILY PRACTICE CLINIC, INC.
Entity Type:Organization
Organization Name:PORTAGE FAMILY PRACTICE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAMBURRO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-499-7591
Mailing Address - Street 1:1413 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2288
Mailing Address - Country:US
Mailing Address - Phone:330-499-7591
Mailing Address - Fax:330-499-0308
Practice Address - Street 1:1413 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2288
Practice Address - Country:US
Practice Address - Phone:330-499-7591
Practice Address - Fax:330-499-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003002261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0507268Medicaid
OH0507268Medicaid
OHPO9268521Medicare ID - Type UnspecifiedGROUP