Healthcare Provider Details

I. General information

NPI: 1306052121
Provider Name (Legal Business Name): ROBERT WILLIAM PUTNAM II MS, ATC L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11932 KING CHURCH AVE NW
UNIONTOWN OH
44685-8220
US

IV. Provider business mailing address

1582 POPPY DR NW
MOGADORE OH
44260-1717
US

V. Phone/Fax

Practice location:
  • Phone: 330-877-5000
  • Fax:
Mailing address:
  • Phone: 330-701-1545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT. 002198
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: