Provider Demographics
NPI:1821128968
Name:PORTAGE HEALTH INC.
Entity Type:Organization
Organization Name:PORTAGE HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODAMSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-483-1045
Mailing Address - Street 1:894 CAMPUS DR
Mailing Address - Street 2:STE B
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1571
Mailing Address - Country:US
Mailing Address - Phone:906-483-1128
Mailing Address - Fax:906-483-1122
Practice Address - Street 1:500 CAMPUS DR,
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1045
Practice Address - Fax:906-483-1044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTAGE HEALTH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI310020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C16002OtherMEDICARE GROUP
MI700C16002OtherBCBSM