Provider Demographics
NPI:1366693145
Name:ENGLEWOOD FAMILY HEALTH CENTER, P.A
Entity Type:Organization
Organization Name:ENGLEWOOD FAMILY HEALTH CENTER, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-926-1828
Mailing Address - Street 1:148 ENGLE STREET, SUITE NUMBER 1
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2581
Mailing Address - Country:US
Mailing Address - Phone:201-569-1530
Mailing Address - Fax:201-569-6022
Practice Address - Street 1:148 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2581
Practice Address - Country:US
Practice Address - Phone:201-569-1530
Practice Address - Fax:201-569-6022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0611859Medicaid
NJG11493OtherUPIN
NJ781484Medicare PIN