Provider Demographics
NPI:1104157064
Name:PORTAGE HEALTH CENTER OCCUPATIONAL HEALTH
Entity type:Organization
Organization Name:PORTAGE HEALTH CENTER OCCUPATIONAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MYBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-392-7064
Mailing Address - Street 1:3545 ARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4297
Mailing Address - Country:US
Mailing Address - Phone:219-759-4604
Mailing Address - Fax:219-759-4604
Practice Address - Street 1:3545 ARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4297
Practice Address - Country:US
Practice Address - Phone:219-759-4604
Practice Address - Fax:219-759-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine