Provider Demographics
NPI:1558322982
Name:PORTER HEALTH SERVICES
Entity Type:Organization
Organization Name:PORTER HEALTH SERVICES
Other - Org Name:PORTAGE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-364-3660
Mailing Address - Street 1:26700 BROOKPARK ROAD EXT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3124
Mailing Address - Country:US
Mailing Address - Phone:800-611-6912
Mailing Address - Fax:440-716-1605
Practice Address - Street 1:3630 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5075
Practice Address - Country:US
Practice Address - Phone:219-759-5791
Practice Address - Fax:219-759-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========003OtherTRICARE
IN=========OtherMEDICAL MUTUAL
INCE0707Medicare ID - Type UnspecifiedRAILROAD
IN=========OtherMEDICAL MUTUAL
IN225800Medicare ID - Type Unspecified