Provider Demographics
NPI:1003868761
Name:PUTNAM, HARVEY WILLIS JR (PA)
Entity type:Individual
Prefix:MR
First Name:HARVEY
Middle Name:WILLIS
Last Name:PUTNAM
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2835 E HIGHWAY 76
Practice Address - Street 2:SUITE 3
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6038
Practice Address - Country:US
Practice Address - Phone:843-423-0230
Practice Address - Fax:843-423-0802
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-07-15
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Provider Licenses
StateLicense IDTaxonomies
SC1074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8103265Medicaid
SC0827PAMedicaid
SC80026764OtherSELECT HEALTH
SCP01210111OtherRAILROAD MCR
SC7736884OtherAETNA
SC933312OtherWELLCARE
NC19CQ2OtherBCBS NC
SCAA12178568Medicare PIN
NCNCK676AMedicare PIN