Provider Demographics
NPI:1841268265
Name:DARTMOUTH MEDICAL WALK IN PC III
Entity type:Organization
Organization Name:DARTMOUTH MEDICAL WALK IN PC III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-996-3311
Mailing Address - Street 1:39 A FAUNCE CORNER ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-996-3311
Mailing Address - Fax:508-997-5352
Practice Address - Street 1:39 A FAUNCE CORNER ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747
Practice Address - Country:US
Practice Address - Phone:508-996-3311
Practice Address - Fax:508-997-5352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703705Medicaid
M21357Medicare ID - Type Unspecified