MEDICARE: STEPHEN RUSSELL BUTLER DO

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	207Q00000X	Family Medicine Physician	154055	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255318721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN RUSSELL BUTLER DO

Provider Business Mailing Address
First Line	:	168 COTTONTAIL DR
Second Line	:
City	:	PORTSMOUTH
State	:	RI
Zip	:	02871-5155
Country	:	US
Telephone Number	:	401-619-1358
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 FAUNCE CORNER RD
Second Line	:
City	:	DARTMOUTH
State	:	MA
Zip	:	02747-4202
Country	:	US
Telephone Number	:	508-996-3311
Fax Number	:	508-997-5352

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

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	07/08/2007

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