Basic Information
| Provider Information | |||||||||
| NPI: | 1568446086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTAGE PATHOLOGY ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5620 SOUTHWYCK BLVD | ||||||||
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| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006277081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6847 N CHESTNUT ST | ||||||||
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| City: | RAVENNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442663929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302970811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3302970811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.