Provider Demographics
NPI:1467648279
Name:PUTNAM E N T PA
Entity Type:Organization
Organization Name:PUTNAM E N T PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENWOOD
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-325-1565
Mailing Address - Street 1:320 ZEAGLER DR
Mailing Address - Street 2:STE 1
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6851
Mailing Address - Country:US
Mailing Address - Phone:386-325-1565
Mailing Address - Fax:386-325-1571
Practice Address - Street 1:320 ZEAGLER DR
Practice Address - Street 2:STE 1
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6851
Practice Address - Country:US
Practice Address - Phone:386-325-1565
Practice Address - Fax:386-325-1571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050554174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064059000Medicaid
FL10676ZMedicare PIN
FLD95362Medicare UPIN