Provider Demographics
NPI:1629413745
Name:IVY CREEK OF BUTLER, LLC
Entity Type:Organization
Organization Name:IVY CREEK OF BUTLER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-376-2963
Mailing Address - Street 1:515 N MIRANDA AVE
Mailing Address - Street 2:
Mailing Address - City:GEORGIANA
Mailing Address - State:AL
Mailing Address - Zip Code:36033-4519
Mailing Address - Country:US
Mailing Address - Phone:334-376-2205
Mailing Address - Fax:334-376-3660
Practice Address - Street 1:515 N MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:GEORGIANA
Practice Address - State:AL
Practice Address - Zip Code:36033-4519
Practice Address - Country:US
Practice Address - Phone:334-376-2205
Practice Address - Fax:334-376-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty