Provider Demographics
NPI:1306965223
Name:CITY OF PORTAGE
Entity type:Organization
Organization Name:CITY OF PORTAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS CHIEF OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-707-7711
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:800-926-6985
Mailing Address - Fax:734-479-6319
Practice Address - Street 1:3401 SWANSON RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4822
Practice Address - Country:US
Practice Address - Phone:219-762-7784
Practice Address - Fax:219-763-9607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00663416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100271470AMedicaid
IN000000234636OtherANTHEM INSURANCE COMP
IN590164506OtherPAMETTO RAILROAD MEDICARE