Provider Demographics
NPI:1922320134
Name:GREGORY PUTALIK, MD PC
Entity Type:Organization
Organization Name:GREGORY PUTALIK, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PUTALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-242-4700
Mailing Address - Street 1:643 E LAKE ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-1240
Mailing Address - Country:US
Mailing Address - Phone:231-242-4734
Mailing Address - Fax:231-242-4700
Practice Address - Street 1:643 E LAKE ST UNIT 4
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-1240
Practice Address - Country:US
Practice Address - Phone:231-242-4734
Practice Address - Fax:231-242-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4081535Medicaid
MIB48955Medicare UPIN
MI4081535Medicaid
MIMI2536Medicare PIN