Provider Demographics
NPI:1306848395
Name:PORTOLESE, TAMMY L (DC)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:L
Last Name:PORTOLESE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DICKERSON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2538
Mailing Address - Country:US
Mailing Address - Phone:215-661-8533
Mailing Address - Fax:215-661-8535
Practice Address - Street 1:118 DICKERSON RD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2538
Practice Address - Country:US
Practice Address - Phone:215-661-8533
Practice Address - Fax:215-661-8535
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007023L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0967764000OtherKEYSTONE & PC
PA2582972OtherAETNA
PA1303194OtherBC / BS
PA047564Medicare ID - Type Unspecified