Provider Demographics
NPI:1194778522
Name:PORTAGE SURGICAL ASSOCIATES INC
Entity type:Organization
Organization Name:PORTAGE SURGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PANZETER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-296-8239
Mailing Address - Street 1:3973 LOOMIS PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1803
Mailing Address - Country:US
Mailing Address - Phone:330-296-8239
Mailing Address - Fax:330-296-6528
Practice Address - Street 1:3973 LOOMIS PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1803
Practice Address - Country:US
Practice Address - Phone:330-296-8239
Practice Address - Fax:330-296-6528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2045263Medicaid
OH9283991Medicare ID - Type Unspecified