Provider Demographics
NPI:1598886616
Name:PORTLAND MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:PORTLAND MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DECESARE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-897-6272
Mailing Address - Street 1:716 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:PA
Mailing Address - Zip Code:18351-0358
Mailing Address - Country:US
Mailing Address - Phone:570-897-6272
Mailing Address - Fax:
Practice Address - Street 1:716 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:PA
Practice Address - Zip Code:18351-0358
Practice Address - Country:US
Practice Address - Phone:570-897-6272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002690L261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
548961OtherUS HEALTHCARE
DE 041920OtherPA BLUE SHIELD
14843OtherGEISENGERS HEALTH CARE
PA001706OtherFIRST PRIORITY
548961OtherUS HEALTHCARE
PAB96678Medicare UPIN