1477514867 NPI number — PORTER HEALTH SERVICES

Table of content: (NPI 1477514867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477514867 NPI number — PORTER HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTER HEALTH SERVICES
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:
1477514867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26700 BROOKPARK ROAD EXT
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
NORTH OLMSTED
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44070-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-611-6912
Provider Business Mailing Address Fax Number:
440-716-1605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 GLENDALE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-3767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-464-0232
Provider Business Practice Location Address Fax Number:
219-759-3807
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAMMOND
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
219-364-3660

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000286384 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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