Provider Demographics
NPI:1710022389
Name:PORTAGE PHYSICAL THERAPIST
Entity Type:Organization
Organization Name:PORTAGE PHYSICAL THERAPIST
Other - Org Name:ALLIED HEALTH REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-9020
Mailing Address - Street 1:388 S MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1064
Mailing Address - Country:US
Mailing Address - Phone:330-543-2110
Mailing Address - Fax:
Practice Address - Street 1:388 S MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1064
Practice Address - Country:US
Practice Address - Phone:330-543-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0916610Medicaid
OH366684Medicare ID - Type UnspecifiedLOCATION INDENTIFIER