Basic Information
| Provider Information | |||||||||
| NPI: | 1912973942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUTNEY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301 | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539010301 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2901 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425518 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 57658-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 57658-20 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 72259 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.