Provider Demographics
NPI:1437600657
Name:PUTNAM COUNTY MEDICAL HOME CLINICS, LLC
Entity Type:Organization
Organization Name:PUTNAM COUNTY MEDICAL HOME CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-737-4704
Mailing Address - Street 1:2221 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63565-1426
Mailing Address - Country:US
Mailing Address - Phone:610-737-4704
Mailing Address - Fax:
Practice Address - Street 1:103 S 18TH ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1642
Practice Address - Country:US
Practice Address - Phone:660-947-2300
Practice Address - Fax:660-947-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207348905Medicaid
IA749127Medicaid
C24545Medicare UPIN