Healthcare Provider Details

I. General information

NPI: 1679782841
Provider Name (Legal Business Name): GREGORY C PUTALIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 E LAKE ST #4
HARBOR SPRINGS MI
49740-1239
US

IV. Provider business mailing address

643 E LAKE ST # 4
HARBOR SPRINGS MI
49740-1239
US

V. Phone/Fax

Practice location:
  • Phone: 231-242-4734
  • Fax: 231-242-4700
Mailing address:
  • Phone: 231-526-5041
  • Fax: 231-242-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301050511
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50511
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: