Healthcare Provider Details

I. General information

NPI: 1912286964
Provider Name (Legal Business Name): OTTER TAIL PODIATRY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E JUNIUS AVE
FERGUS FALLS MN
56537-2819
US

IV. Provider business mailing address

120 E JUNIUS AVE
FERGUS FALLS MN
56537-2819
US

V. Phone/Fax

Practice location:
  • Phone: 218-736-6868
  • Fax: 218-736-6017
Mailing address:
  • Phone: 218-736-6868
  • Fax: 218-736-6017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number828
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number828
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number828
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number828
License Number StateMN

VIII. Authorized Official

Name: DR. MARC J BUTCHER
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 218-736-6868