Healthcare Provider Details

I. General information

NPI: 1336496058
Provider Name (Legal Business Name): BENJAMIN WILLIAM BUTCHER D.P.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 OLD JACKSONVILLE RD SUITE C
SPRINGFIELD IL
62704-7437
US

IV. Provider business mailing address

2901 OLD JACKSONVILLE RD SUITE C
SPRINGFIELD IL
62704-7437
US

V. Phone/Fax

Practice location:
  • Phone: 217-793-0000
  • Fax: 217-793-5201
Mailing address:
  • Phone: 217-793-0000
  • Fax: 217-793-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070019325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: