1306965223 NPI number — CITY OF PORTAGE

Table of content: (NPI 1306965223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306965223 NPI number — CITY OF PORTAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF PORTAGE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306965223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-926-6985
Provider Business Mailing Address Fax Number:
734-479-6319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 SWANSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46368-4822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-762-7784
Provider Business Practice Location Address Fax Number:
219-763-9607
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ROY
Authorized Official Middle Name:
Authorized Official Title or Position:
EMS CHIEF OF OPERATIONS
Authorized Official Telephone Number:
219-707-7711

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0066 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100271470A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000234636 . This is a "ANTHEM INSURANCE COMP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 590164506 . This is a "PAMETTO RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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