Healthcare Provider Details

I. General information

NPI: 1295737633
Provider Name (Legal Business Name): CHARLES W BUTRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6730 W 121ST ST
OVERLAND PARK KS
66209-2002
US

IV. Provider business mailing address

6730 W 121ST ST
OVERLAND PARK KS
66209-2002
US

V. Phone/Fax

Practice location:
  • Phone: 913-307-0044
  • Fax: 913-948-5380
Mailing address:
  • Phone: 913-307-0044
  • Fax: 913-296-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA13916
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number042241
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: