MEDICARE: PUTNAM CLINICAL LABORATORIES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	800008234	FL

General Provider Information

NPI Number	:	1336159979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUTNAM CLINICAL LABORATORIES INC

Provider Business Mailing Address
First Line	:	700 ZEAGLER DR STE 8
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3826
Country	:	US
Telephone Number	:	386-328-4036
Fax Number	:	386-328-7397

Provider Business Practice Location Address
First Line	:	700 ZEAGLER DR STE 8
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3826
Country	:	US
Telephone Number	:	386-328-4036
Fax Number	:	386-328-7397

Authorized Official
Title or Position	:	OWNER
Name	:	ELIO MADAN
Credential	:	MD
Telephone Number	:	386-328-4036

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	02/13/2009

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