Provider Demographics
NPI:1124467717
Name:PORTILLA MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PORTILLA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:305-631-1220
Mailing Address - Street 1:330 SW 27TH AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2961
Mailing Address - Country:US
Mailing Address - Phone:305-631-1220
Mailing Address - Fax:305-631-1251
Practice Address - Street 1:330 SW 27TH AVE
Practice Address - Street 2:STE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2961
Practice Address - Country:US
Practice Address - Phone:305-631-1220
Practice Address - Fax:305-631-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010921800Medicaid
FLHU244AOtherMEDICARE PTAN