Provider Demographics
NPI:1508174871
Name:WESTSIDE HEAD & NECK
Entity Type:Organization
Organization Name:WESTSIDE HEAD & NECK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-204-4111
Mailing Address - Street 1:3831 HUGHES AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2751
Mailing Address - Country:US
Mailing Address - Phone:310-204-4111
Mailing Address - Fax:310-204-4474
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-204-4111
Practice Address - Fax:310-204-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DR6472OtherRAIL ROAD
FA716AMedicare PIN