Basic Information
| Provider Information | |||||||||
| NPI: | 1093935199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUTNAM MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 SUITE B TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047606040 | ||||||||
| FaxNumber: | 3047606042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 SUITE B TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047606040 | ||||||||
| FaxNumber: | 3047606042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SLOAN | ||||||||
| AuthorizedOfficialFirstName: | CLINTON | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER OF PRACTICE PUTNAM MEDICAL GR | ||||||||
| AuthorizedOfficialTelephone: | 3047606040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0074222000 | 05 | WV | MEDICAID |