Provider Demographics
NPI:1760501043
Name:BUTLER, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73276
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21273-0001
Mailing Address - Country:US
Mailing Address - Phone:301-631-8103
Mailing Address - Fax:
Practice Address - Street 1:110 S PACA ST
Practice Address - Street 2:SIXTH FLOOR, SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1642
Practice Address - Country:US
Practice Address - Phone:410-328-8025
Practice Address - Fax:410-328-8028
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0046145146D00000X
MDH46145207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD122731900Medicaid
MDH254OtherMEDICARE GROUP NUMBER
MDF98556Medicare UPIN
MD406LMedicare PIN
MDH254OtherMEDICARE GROUP NUMBER