Healthcare Provider Details

I. General information

NPI: 1720034226
Provider Name (Legal Business Name): PORTLAND PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 REDBUD DR SUITE E
PORTLAND TN
37148-1617
US

IV. Provider business mailing address

103 REDBUD DR SUITE E
PORTLAND TN
37148-1617
US

V. Phone/Fax

Practice location:
  • Phone: 615-325-1206
  • Fax: 615-325-1245
Mailing address:
  • Phone: 615-325-1206
  • Fax: 615-325-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFF RYDBURG
Title or Position: VP
Credential:
Phone: 615-373-7415