Basic Information
Provider Information | |||||||||
NPI: | 1902065188 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUTLER | ||||||||
FirstName: | MARCUS | ||||||||
MiddleName: | WILLIAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MB BCH BAO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTLER | ||||||||
OtherFirstName: | MARK | ||||||||
OtherMiddleName: | WILLIAM | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MB BCH BAO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 525 E 70TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100214872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127462250 | ||||||||
FaxNumber: | 2127468808 | ||||||||
Practice Location | |||||||||
Address1: | 525 E 70TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100214872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127462250 | ||||||||
FaxNumber: | 2127468808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2008 | ||||||||
LastUpdateDate: | 06/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | AN1865243P43 | NY | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.