Provider Demographics
NPI:1912286964
Name:OTTER TAIL PODIATRY P.C.
Entity Type:Organization
Organization Name:OTTER TAIL PODIATRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:218-736-6868
Mailing Address - Street 1:120 E JUNIUS AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2819
Mailing Address - Country:US
Mailing Address - Phone:218-736-6868
Mailing Address - Fax:218-736-6017
Practice Address - Street 1:120 E JUNIUS AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2819
Practice Address - Country:US
Practice Address - Phone:218-736-6868
Practice Address - Fax:218-736-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN828213E00000X, 213EP1101X, 213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619065398OtherNPI