Provider Demographics
NPI:1386970481
Name:PORTAGE HEALTH INC.
Entity type:Organization
Organization Name:PORTAGE HEALTH INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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 1:894 CAMPUS DR
Mailing Address - Street 2:STE. B
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1571
Mailing Address - Country:US
Mailing Address - Phone:906-483-1128
Mailing Address - Fax:906-483-1122
Practice Address - Street 1:945 9TH ST
Practice Address - Street 2:
Practice Address - City:LAKE LINDEN
Practice Address - State:MI
Practice Address - Zip Code:49945-1100
Practice Address - Country:US
Practice Address - Phone:906-483-1030
Practice Address - Fax:906-296-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C16002OtherBCBSM
MI0C16002Medicare PIN