Organization
PUTNAM COUNTY MEDICAL HOME CLINICS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAWN FAIRLEY (SOLE OWNER)
(610) 737-4704
Entity
Organization
Contact information
Practice address
103 S 18TH ST, UNIONVILLE, MO 63565-1642
(660) 947-2300
(660) 947-2307
Mailing address
2221 GREEN ST, UNIONVILLE, MO 63565-1426
(610) 737-4704
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207348905
—
MO
05
—
749127
—
IA
Enumeration date
10/24/2016
Last updated
10/24/2016
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