Provider Demographics
NPI:1235328980
Name:PORTAGE REGIONAL GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:PORTAGE REGIONAL GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-296-7256
Mailing Address - Street 1:330 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2287
Mailing Address - Country:US
Mailing Address - Phone:330-296-7256
Mailing Address - Fax:330-296-0127
Practice Address - Street 1:330 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2287
Practice Address - Country:US
Practice Address - Phone:330-296-7256
Practice Address - Fax:330-296-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0131593Medicaid
OH0131593Medicaid