Basic Information
Provider Information
NPI: 1588760383
EntityType: 2
ReplacementNPI:  
OrganizationName: PUTNAM COUNTY PRIMARY CARE LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 450718
Address2:  
City: WESTLAKE
State: OH
PostalCode: 441450614
CountryCode: US
TelephoneNumber: 8005144390
FaxNumber: 4408083675
Practice Location
Address1: 1740 N PERRY ST
Address2: SUITE A
City: OTTAWA
State: OH
PostalCode: 458751173
CountryCode: US
TelephoneNumber: 4195230012
FaxNumber: 4195233416
Other Information
ProviderEnumerationDate: 09/16/2006
LastUpdateDate: 07/01/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: EIDEN
AuthorizedOfficialFirstName: JEFFREY
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4195230012
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
207Q00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
DC469001OHRAILROAD CAREOTHER
250240105OH MEDICAID
559727000101OHDMEOTHER


Home