Healthcare Provider Details

I. General information

NPI: 1649058934
Provider Name (Legal Business Name): GREG JAMES PUTNAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N COURT ST
WESTMINSTER MD
21157-5192
US

IV. Provider business mailing address

450 AVENEL CIR APT T4
WESTMINSTER MD
21158-4130
US

V. Phone/Fax

Practice location:
  • Phone: 410-751-3033
  • Fax:
Mailing address:
  • Phone: 301-448-0535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberP-355288-367-734
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: