Provider Demographics
NPI:1679230510
Name:PORTLAND MEDICAL
Entity Type:Organization
Organization Name:PORTLAND MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NAZARENUS
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:615-804-9470
Mailing Address - Street 1:106 PIRES LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-4900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1413
Practice Address - Country:US
Practice Address - Phone:615-325-6755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service