Provider Demographics
NPI:1275743262
Name:BUTTERICK AND HALL MDS PA
Entity Type:Organization
Organization Name:BUTTERICK AND HALL MDS PA
Other - Org Name:GULFCOAST VEIN & LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUTTERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-7512
Mailing Address - Street 1:302 BRYAN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5337
Mailing Address - Country:US
Mailing Address - Phone:813-681-7512
Mailing Address - Fax:813-684-8974
Practice Address - Street 1:302 BRYAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5337
Practice Address - Country:US
Practice Address - Phone:813-681-7512
Practice Address - Fax:813-684-8974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1798Medicare ID - Type UnspecifiedGOUP MEDICARE ID NUMBER