=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306965223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF PORTAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 03/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 SWANSON RD
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-762-7784
-----------------------------------------------------
Fax | 219-763-9607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2122
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-926-6985
-----------------------------------------------------
Fax | 734-479-6319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMS CHIEF OF OPERATIONS
-----------------------------------------------------
Name | ROY JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-707-7711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 0066
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------