1023066404 NPI number — SAMUEL G PUTNAM III MD

Table of content: SAMUEL G PUTNAM III MD (NPI 1023066404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023066404 NPI number — SAMUEL G PUTNAM III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUTNAM
Provider First Name:
SAMUEL
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023066404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26500 AGOURA RD STE 102-587
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALABASAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91302-1952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-880-8605
Provider Business Mailing Address Fax Number:
818-579-7916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 PHYSICIANS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-655-2136
Provider Business Practice Location Address Fax Number:
662-996-2214
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD041221E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: C1-0011573 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: MD041221E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: C1-0011573 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 63241 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 28916 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8215722 . This is a "CIGNA HMO/PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1172545 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0546464000 . This is a "IBC - PC/KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 710371 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012723560016 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0546464000 . This is a "AMERIHEALTH/INTERCOUNTY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30026885 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 300099781 . This is a "RRM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7929044 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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