Provider Demographics
NPI:1720570930
Name:PORTELLI, JOSEPH PORTELLI MATTHEW
Entity Type:Individual
Prefix:
First Name:JOSEPH PORTELLI
Middle Name:MATTHEW
Last Name:PORTELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41723 GLADE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3773
Mailing Address - Country:US
Mailing Address - Phone:734-377-1731
Mailing Address - Fax:734-377-1731
Practice Address - Street 1:37450 SCHOOLCRAFT RD STE 110
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1000
Practice Address - Country:US
Practice Address - Phone:734-458-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program