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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | DC4690 | 01 | OH | RAILROAD CARE | OTHER | 2502401 | 05 | OH |   | MEDICAID | 5597270001 | 01 | OH | DME | OTHER |