Provider Demographics
NPI:1215931068
Name:PORTAGE HEALTH INC
Entity type:Organization
Organization Name:PORTAGE HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-483-1500
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1000
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000055207P00000X
MI310020282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640C1200OtherBLUE CROSS AUDIOLOGY GROUP
MI700C16002OtherBLUE CROSS GROUP
MI5171691Medicaid
MI700C16002OtherBLUE CROSS GROUP
MI230108Medicare Oscar/Certification
MI0C16002Medicare PIN