Healthcare Provider Details

I. General information

NPI: 1154758167
Provider Name (Legal Business Name): PORTAGE PHYSICIAN PRACTICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 9TH ST
LAKE LINDEN MI
49945-1100
US

IV. Provider business mailing address

103 POWELL CT
BRENTWOOD TN
37027-5079
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1030
  • Fax: 906-296-0521
Mailing address:
  • Phone: 615-372-8500
  • Fax: 615-372-8572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MONICA BOWMAN
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7000