MEDICARE: PORTLAND SURGICAL, LLC

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	208600000X	Surgery 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	:	1548216062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND SURGICAL, LLC

Provider Business Mailing Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE D
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-323-8306
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE D
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-323-8306
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	MR. CHUCK LOCKE
Credential	:
Telephone Number	:	615-373-7604

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/29/2007

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Directions to “PORTLAND SURGICAL, LLC ” Practice Location

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