Provider Demographics
NPI:1407994452
Name:COUNTY OF PUTNAM
Entity Type:Organization
Organization Name:COUNTY OF PUTNAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, ACCOUNTING
Authorized Official - Phone:815-872-5091
Mailing Address - Street 1:220 E HIGH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HENNEPIN
Mailing Address - State:IL
Mailing Address - Zip Code:61327-9515
Mailing Address - Country:US
Mailing Address - Phone:815-925-7326
Mailing Address - Fax:815-925-7001
Practice Address - Street 1:220 E. HIGH ST
Practice Address - Street 2:
Practice Address - City:HENNEPIN
Practice Address - State:IL
Practice Address - Zip Code:61327
Practice Address - Country:US
Practice Address - Phone:815-925-7326
Practice Address - Fax:815-925-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL600002468Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL553560Medicare ID - Type UnspecifiedMEDICARE B