Healthcare Provider Details

I. General information

NPI: 1114062031
Provider Name (Legal Business Name): PUTNAM FAMILY PRACTICE ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 TEAYS VALLEY RD
HURRICANE WV
25526-8728
US

IV. Provider business mailing address

3952 TEAYS VALLEY RD
HURRICANE WV
25526-8728
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6736
  • Fax: 304-757-0582
Mailing address:
  • Phone: 304-757-6736
  • Fax: 304-757-0582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14044
License Number StateWV

VIII. Authorized Official

Name: DR. RANDALL WATSON PETERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-757-6736