Basic Information
| Provider Information | |||||||||
| NPI: | 1780771923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUTNAM AMBULATORY SURGERY CENTER LLC | ||||||||
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| OtherOrganizationName: | PUTNAM AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 ZEAGLER DR | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321773815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863285711 | ||||||||
| FaxNumber: | 3863258178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 09/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRACEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.