Basic Information
| Provider Information | |||||||||
| NPI: | 1013129394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTREY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 CENTER RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | AVON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440111239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409374600 | ||||||||
| FaxNumber: | 4409374605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35058431 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3025372 | 05 | OH | MEDICAID | 0782612 | 05 | OH | MEDICAID |