Provider Demographics
NPI:1609968726
Name:PORTAGE FAMILY MEDICINE, INC
Entity Type:Organization
Organization Name:PORTAGE FAMILY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-626-5566
Mailing Address - Street 1:9480 ROSEMONT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4569
Mailing Address - Country:US
Mailing Address - Phone:330-626-5566
Mailing Address - Fax:330-626-2042
Practice Address - Street 1:9480 ROSEMONT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4569
Practice Address - Country:US
Practice Address - Phone:330-626-5566
Practice Address - Fax:330-626-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0796116Medicaid
OH0796116Medicaid