Healthcare Provider Details

I. General information

NPI: 1588760383
Provider Name (Legal Business Name): PUTNAM COUNTY PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 N PERRY ST SUITE A
OTTAWA OH
45875-1173
US

IV. Provider business mailing address

PO BOX 450718
WESTLAKE OH
44145-0614
US

V. Phone/Fax

Practice location:
  • Phone: 419-523-0012
  • Fax: 419-523-3416
Mailing address:
  • Phone: 800-514-4390
  • Fax: 440-808-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY S EIDEN
Title or Position: OWNER
Credential: MD
Phone: 419-523-0012