Healthcare Provider Details

I. General information

NPI: 1245326149
Provider Name (Legal Business Name): SOUTHERN PINES FAMILY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64629 HIGHWAY 41
PEARL RIVER LA
70452-3611
US

IV. Provider business mailing address

PO BOX 1659
PEARL RIVER LA
70452-1659
US

V. Phone/Fax

Practice location:
  • Phone: 985-863-7100
  • Fax:
Mailing address:
  • Phone: 985-863-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN BUTT
Title or Position: MEMBER
Credential: M D
Phone: 985-863-7100