Basic Information
| Provider Information | |||||||||
| NPI: | 1437600657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUTNAM COUNTY MEDICAL HOME CLINICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | UNIONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635651426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107374704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | UNIONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635651642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6609472300 | ||||||||
| FaxNumber: | 6609472307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | FAIRLEY | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6107374704 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 207348905 | 05 | MO | MEDICAID | 749127 | 05 | IA | MEDICAID |