Provider Demographics
NPI:1720034226
Name:PORTLAND PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PORTLAND PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7415
Mailing Address - Street 1:103 REDBUD DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1617
Mailing Address - Country:US
Mailing Address - Phone:615-325-1206
Mailing Address - Fax:615-325-1245
Practice Address - Street 1:103 REDBUD DR
Practice Address - Street 2:SUITE E
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1617
Practice Address - Country:US
Practice Address - Phone:615-325-1206
Practice Address - Fax:615-325-1245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HTI HOSPITAL HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734188Medicaid
DF6970Medicare PIN
TN3734188Medicare PIN