Basic Information
| Provider Information | |||||||||
| NPI: | 1982851390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRENT A. BUTCHER, MD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3639 MIDWAY DR | ||||||||
| Address2: | SUITE B, #412 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921105254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192586200 | ||||||||
| FaxNumber: | 6192580028 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 W LEGION RD | ||||||||
| Address2: | |||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922277780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603514848 | ||||||||
| FaxNumber: | 7603514849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUTCHER | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6199909317 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | A67738 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
No ID Information.