Provider Demographics
NPI:1790820355
Name:PORTAGE PHYSICAL THERAPISTS, INC
Entity Type:Organization
Organization Name:PORTAGE PHYSICAL THERAPISTS, INC
Other - Org Name:ALLIED HEALTH REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRARA-MATHYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-9020
Mailing Address - Street 1:771 N FREEDOM ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2470
Mailing Address - Country:US
Mailing Address - Phone:330-297-9020
Mailing Address - Fax:330-297-9094
Practice Address - Street 1:35 N CLEVELAND AVE
Practice Address - Street 2:STE C
Practice Address - City:MOGADORE
Practice Address - State:OH
Practice Address - Zip Code:44260-1365
Practice Address - Country:US
Practice Address - Phone:330-628-0736
Practice Address - Fax:330-628-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2955306Medicaid
OH2955306Medicaid