Basic Information
| Provider Information | |||||||||
| NPI: | 1275057994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUTNAM RADIATION ONCOLOGY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CANCER CENTER OF PUTNAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 600 ZEAGLER DR | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321773811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863267900 | ||||||||
| FaxNumber: | 3863252214 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 ZEAGLER DR | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321773811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863267900 | ||||||||
| FaxNumber: | 3863252214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617141482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | PENDING | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.