MEDICARE: PORTAGE FAMILY PRACTICE CLINIC, 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	261Q00000X	Clinic/Center	34003002	OH

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	:	1083767677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE FAMILY PRACTICE CLINIC, INC.

Provider Business Mailing Address
First Line	:	1413 PORTAGE ST NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2288
Country	:	US
Telephone Number	:	330-499-7591
Fax Number	:	330-499-0308

Provider Business Practice Location Address
First Line	:	1413 PORTAGE ST NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2288
Country	:	US
Telephone Number	:	330-499-7591
Fax Number	:	330-499-0308

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEONARD D TAMBURRO
Credential	:	D.O.
Telephone Number	:	330-499-7591

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	10/25/2011

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