Provider Demographics
NPI:1881686798
Name:PORTA-MED, INC.
Entity Type:Organization
Organization Name:PORTA-MED, INC.
Other - Org Name:PORTA-MED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BALLAH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:419-663-1367
Mailing Address - Street 1:12513 US HIGHWAY 250 N
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:OH
Mailing Address - Zip Code:44846-9546
Mailing Address - Country:US
Mailing Address - Phone:800-589-2515
Mailing Address - Fax:419-499-2664
Practice Address - Street 1:12513 US HIGHWAY 250 N
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:OH
Practice Address - Zip Code:44846-9546
Practice Address - Country:US
Practice Address - Phone:800-589-2515
Practice Address - Fax:419-499-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000287994OtherANTHEM BLUE CROSS
1275060OtherUNITED MINE WORKERS
OH0416133Medicaid
1275060OtherUNITED MINE WORKERS