Healthcare Provider Details

I. General information

NPI: 1215067798
Provider Name (Legal Business Name): GEORGE M.S. PUTNAM CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 NW SAMARITAN DR SUITE E300
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

3600 NW SAMARITAN DR SUITE E300
CORVALLIS OR
97330-3737
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5223
  • Fax: 541-768-5014
Mailing address:
  • Phone: 541-768-5223
  • Fax: 541-768-5014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: