MEDICARE: PORTAGE FAMILY MEDICINE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609968726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE FAMILY MEDICINE, INC

Provider Business Mailing Address
First Line	:	9480 ROSEMONT DR
Second Line	:	SUITE 100
City	:	STREETSBORO
State	:	OH
Zip	:	44241-4569
Country	:	US
Telephone Number	:	330-626-5566
Fax Number	:	330-626-2042

Provider Business Practice Location Address
First Line	:	9480 ROSEMONT DR
Second Line	:	SUITE 100
City	:	STREETSBORO
State	:	OH
Zip	:	44241-4569
Country	:	US
Telephone Number	:	330-626-5566
Fax Number	:	330-626-2042

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. LORA J HAVER
Credential	:
Telephone Number	:	330-626-5566

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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Directions to “PORTAGE FAMILY MEDICINE, INC ” Practice Location

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