MEDICARE: PORTAGE PHYSICAL THERAPISTS, 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	225100000X	Physical Therapist		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	:	1790820355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE PHYSICAL THERAPISTS, INC

Provider Business Mailing Address
First Line	:	771 N FREEDOM ST
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-2470
Country	:	US
Telephone Number	:	330-297-9020
Fax Number	:	330-297-9094

Provider Business Practice Location Address
First Line	:	35 N CLEVELAND AVE
Second Line	:	STE C
City	:	MOGADORE
State	:	OH
Zip	:	44260-1365
Country	:	US
Telephone Number	:	330-628-0736
Fax Number	:	330-628-0739

Authorized Official
Title or Position	:	C.E.O.
Name	:	MRS. DARBIE FERRARA-MATHYS
Credential	:
Telephone Number	:	330-297-9020

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	05/15/2013

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