Basic Information
| Provider Information | |||||||||
| NPI: | 1609929785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTLER-ABSHIRE MEDICAL CLINIC, APMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 926 FRANCES DR | ||||||||
| Address2: | |||||||||
| City: | HAYNESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710386100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186240554 | ||||||||
| FaxNumber: | 3186243782 | ||||||||
| Practice Location | |||||||||
| Address1: | 926 FRANCES DR | ||||||||
| Address2: | |||||||||
| City: | HAYNESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710386100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186240554 | ||||||||
| FaxNumber: | 3186243782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 05/14/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABSHIRE | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3186240554 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 1480 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1944327 | 05 | LA | MEDICAID |