MEDICARE: COLLIN M BUTLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	TM626888	OH
2	3747P1801X	Personal Care Attendant	TM626888	OH
3	376J00000X	Homemaker	TM626888	OH

General Provider Information

NPI Number	:	1083447841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN M BUTLER

Provider Business Mailing Address
First Line	:	7287 HYDE PARK DR APT 205
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-5631
Country	:	US
Telephone Number	:	330-241-0784
Fax Number	:

Provider Business Practice Location Address
First Line	:	7287 HYDE PARK DR APT 205
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-5631
Country	:	US
Telephone Number	:	330-241-0784
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	10/10/2024

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