Provider Demographics
NPI:1023070752
Name:BUTALID, ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:ALBERTO
Middle Name:
Last Name:BUTALID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14505 STATE ROUTE 127
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-6485
Mailing Address - Country:US
Mailing Address - Phone:618-594-8924
Mailing Address - Fax:618-594-7918
Practice Address - Street 1:14505 STATE ROUTE 127
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-6485
Practice Address - Country:US
Practice Address - Phone:618-594-8924
Practice Address - Fax:618-594-7918
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070872207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDD8320OtherRR MEDICARE GROUP
IL208959OtherGROUP
IL036080872Medicaid
IL208959OtherGROUP
ILC48407Medicare UPIN