Basic Information
| Provider Information | |||||||||
| NPI: | 1245287010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTILLA | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 27750 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 16691B1 | 01 | MN | MNBS # | OTHER | 1700491 | 01 | MN | MEDICA # | OTHER | 1669B2 | 01 | MN | MNBS # | OTHER | MN200018 | 01 | MN | LHS/BANNERHEALTH # | OTHER | 036267100 | 05 | MN | MEDICAID | 572128 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | HP25820 | 01 | MN | HEALTHPARTNERS # | OTHER | 13280 | 05 | MN | MEDICAID | 142047 | 01 | MN | UCARE # | OTHER | 16691PO | 01 | MN | MNBS # | OTHER | 2611 | 01 | MN | NDBS # | OTHER | DA9031015667 | 01 | MN | PREFERRED ONE # | OTHER |