Provider Demographics
NPI:1629185756
Name:PORTLAND ORTHOPAEDIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:PORTLAND ORTHOPAEDIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-266-3300
Mailing Address - Street 1:1299 PORTLAND AVENUE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-3300
Mailing Address - Fax:585-266-2163
Practice Address - Street 1:1299 PORTLAND AVENUE
Practice Address - Street 2:SUITE 16
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-3300
Practice Address - Fax:585-266-2163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1436371207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01430097Medicaid
NY0181311590OtherEXCELLOS
NY102371CUOtherPREFERRED CARE
NY102371CUOtherPREFERRED CARE
NY01430097Medicaid