Portage Physician Practices Inc
Organization Active NPI Rural Health Clinic/Center · Calumet, MI
NPI 1164106910 · NPPES record last updated Oct 12, 2023
Key facts
- NPI
- 1164106910
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- PORTAGE PHYSICIAN PRACTICES INC
- Practice address
- 56720 Calumet Ave Ste B
Calumet, MI 49913-1967 - Phone
- (906) 481-8952
- Fax
- (906) 337-4049
- NPI assigned
- Jun 12, 2023
- Organization subpart
- No
Authorized official
- Name
- Monica Bowman
- Title
- President
- Phone
- (615) 920-7000
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 4
Facilities with the same owner 193
Practitioners 150
-
Khurshaid Alam, MD
-
Jenny M Bausano, FNP
-
Austin Bramwell, MD
-
Jennifer Lynell Bryan, PA-C
-
Jessica Caulkins, FNP-C
-
Toni M Clisch, NP-C
-
Robert M Doane, M.D.
-
Adnan Ali Fateh, M.D.
-
Sharon Renee Helmer, M.D.
-
Emily Johnson, MD
-
Bobbi L Jorkos, MD
-
Terry Kinzel, MD
-
Tara Lynn Lassila, P.A.
-
William Liston, DO
-
Paul A Lyle, M.D.
-
Melissa Sue Meier, APRN
-
Suzanne J Miron, NP-C
-
Andre Z Oulai, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D2077796 | Portage Physician Practices, Inc | Certificate of waiver | May 14, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MI
Rural health clinic certification: CCN 238941
- Legal name
- PORTAGE PHYSICIAN PRACTICES INC
- Doing business as
- UP MEDICAL GROUP - PORTAGE EXPRESS CARE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 23, 2024
- Last certification
- Apr 23, 2024
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Enrollment address
- 56720 Calumet Ave
Ste B
Calumet, MI 49913-1905
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Lifepoint Holdings 2 LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
| Portage Health Foundation |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 20% |
| Pamela Kane |
Corporate Officer |
Jul 1, 2023 | |
| Portage Holding Company LLC |
5% Or Greater Direct Ownership Interest | Jul 1, 2023 | 100% |
| DSB Acquisition LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
| Laura C Hinson |
Corporate Officer |
Mar 12, 2025 | |
| Lifepoint Hospitals Holdings LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
| Historic Lifepoint Hospitals, LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
| Lifepoint Health Inc |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
| Charlotte E Lawrence |
Corporate Officer |
Jul 1, 2023 | |
| Klaus Michael Boel |
Corporate Officer |
Aug 19, 2024 | |
| W-2 Managing Employee | Aug 19, 2024 | ||
| John Michael Grooms |
Corporate Officer |
Jul 1, 2023 | |
| Christopher J Monte |
Corporate Officer |
Jul 1, 2023 | |
| Legacy Lifepoint Health LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 80% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20131210001058 | MI | Part B Supplier - Clinic/Group Practice | 6103053509 |
Receives reassigned benefits from 150 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Calumet, MI; Hancock, MI; Houghton, MI; Lake Linden, MI |
| O20231018001783 | MI | Part a Provider - Rural Health Clinic | 6103053509 | Practice locations: Calumet, MI |
National Provider Directory
- Tax ID family
- Portage Physician Practices Inc
Locations
56720 Calumet Ave
Ste B
Calumet, MI 49913
Phone (906) 481-8952
500 Campus Dr
Ste 1
Hancock, MI 49930
Phone (906) 483-1040
500 Campus Dr
Ste 3
Hancock, MI 49930
Phone (906) 483-1050
945 9th St
Lake Linden, MI 49945
Phone (906) 483-1000
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
56720 Calumet Ave Ste B
Calumet, MI 49913-1967
Mailing address
330 Seven Springs Way
Brentwood, TN 37027-5098
Phone (615) 920-7000
Other names
- UP Medical Group - Portage Express Care
Other providers in Calumet, MI
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- Susan Louise Peterson
- Phoenix House Inc.
- Krista Lynn Pietila
- Bradley Pinet
- Psychology Associates of the Keweenaw PC
- Psychology Associates of the Keweenaw, P.C.
- Brianna Rahn
- Dean W Raymond
- Glenda Charlene Reynolds
All providers in Calumet, MI · Rural Health Clinic/Center in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 12, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.