1093723595 NPI number — BUTTELMAN MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093723595 NPI number — BUTTELMAN MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUTTELMAN MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093723595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17075 DEVONSHIRE ST STE 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91325-5411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-832-7802
Provider Business Mailing Address Fax Number:
818-832-7805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17075 DEVONSHIRE ST STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-5411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-832-7802
Provider Business Practice Location Address Fax Number:
818-832-7805
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUTTELMAN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PHYSIAN/OWNER
Authorized Official Telephone Number:
818-832-7802

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A47864 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A478640 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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