Provider Demographics
NPI:1114062031
Name:PUTNAM FAMILY PRACTICE ASSOCIATES INC.
Entity Type:Organization
Organization Name:PUTNAM FAMILY PRACTICE ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WATSON
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-757-6736
Mailing Address - Street 1:3952 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8728
Mailing Address - Country:US
Mailing Address - Phone:304-757-6736
Mailing Address - Fax:304-757-0582
Practice Address - Street 1:3952 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8728
Practice Address - Country:US
Practice Address - Phone:304-757-6736
Practice Address - Fax:304-757-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057148000Medicaid
WV1184694739OtherNPI (INDIVIDUAL)
WV0553011Medicare ID - Type UnspecifiedMEDICARE
WVD65342Medicare UPIN