Provider Demographics
NPI:1083809784
Name:PORTAGE INTERNAL MEDICINE ASSOCIATES LLC
Entity Type:Organization
Organization Name:PORTAGE INTERNAL MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEPERRO
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:330-346-0800
Mailing Address - Street 1:PO BOX 45519
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-0519
Mailing Address - Country:US
Mailing Address - Phone:800-514-4390
Mailing Address - Fax:440-808-3675
Practice Address - Street 1:503 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-5824
Practice Address - Country:US
Practice Address - Phone:330-645-6463
Practice Address - Fax:330-645-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006535207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2192863Medicaid
OHDO7407OtherRAILROAD CARE
OH9371411Medicare PIN