Provider Demographics
NPI:1184786188
Name:PORTAGE HEALTH INC
Entity type:Organization
Organization Name:PORTAGE HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-483-1501
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1720
Mailing Address - Fax:906-483-1735
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:906-483-1720
Practice Address - Fax:906-483-1735
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTAGE HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171691Medicaid
MI5171691Medicaid
MI0C16002Medicare PIN