MEDICARE: PORTLAND PRIMARY CARE 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	207R00000X	Internal Medicine 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	:	1720034226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE E
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-1206
Fax Number	:	615-325-1245

Provider Business Practice Location Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE E
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-1206
Fax Number	:	615-325-1245

Authorized Official
Title or Position	:	VP
Name	:	JEFF RYDBURG
Credential	:
Telephone Number	:	615-373-7415

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	12/11/2007

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Directions to “PORTLAND PRIMARY CARE LLC ” Practice Location

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