Provider Demographics
NPI:1851454847
Name:PUTNAM PHYSICAL MEDICINE & REHABILITATION PC
Entity Type:Organization
Organization Name:PUTNAM PHYSICAL MEDICINE & REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORELEI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-628-2004
Mailing Address - Street 1:880 S LAKE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-4771
Mailing Address - Country:US
Mailing Address - Phone:845-628-4400
Mailing Address - Fax:
Practice Address - Street 1:880 S LAKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4771
Practice Address - Country:US
Practice Address - Phone:845-628-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206144204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG45481Medicare UPIN
NY1205883857Medicare ID - Type UnspecifiedNPI (IND)