Provider Demographics
NPI:1598757841
Name:PUTT, MICHAEL C (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:PUTT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2005
Mailing Address - Country:US
Mailing Address - Phone:662-328-4542
Mailing Address - Fax:662-328-4783
Practice Address - Street 1:2429 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2005
Practice Address - Country:US
Practice Address - Phone:662-328-4542
Practice Address - Fax:662-328-4783
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2390225100000X
ALPTH5787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ29560Medicare UPIN
MS650000280Medicare ID - Type Unspecified