Basic Information
| Provider Information | |||||||||
| NPI: | 1730172297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTCHER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | S | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | 3044386819 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | 3044386819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1829 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7652215 | 01 | WV | AETNA | OTHER | H22519 | 01 | WV | TRICARE | OTHER | 1713064 | 01 | WV | BC/BS | OTHER | 1802427000 | 05 | WV | MEDICAID | 80190394 | 01 | WV | RR MEDICARE | OTHER |