=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750825311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUTNAM PULMONARY & PRIMARY CARE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2016
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 ZEAGLER DR
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-530-2749
-----------------------------------------------------
Fax | 855-313-6017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 ZEAGLER DR
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-530-2749
-----------------------------------------------------
Fax | 855-313-6017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE/CLINICAL MANAGER
-----------------------------------------------------
Name | MRS. DONNA H FEIBELMAN
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 386-530-2749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | ME38708
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------