MEDICARE: MR. TRENT LYDELL BUTLER PT

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	225100000X	Physical Therapist	PT1156	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00147565	OTHER	MS	RRMEDICARE
2	512I650002	OTHER	MS	OLD MEDICARE PTAN
5	P00618853	OTHER	MS	UP MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	302II655874	OTHER	MS	PROVIDER TRANSACTION ACCESS NUMBER

General Provider Information

NPI Number	:	1043241722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRENT LYDELL BUTLER PT

Provider Business Mailing Address
First Line	:	1883 HIGHWAY 43 S
Second Line	:	SUITE C
City	:	CANTON
State	:	MS
Zip	:	39046-8405
Country	:	US
Telephone Number	:	601-859-2906
Fax Number	:	601-859-0483

Provider Business Practice Location Address
First Line	:	1883 HIGHWAY 43 S
Second Line	:	SUITE C
City	:	CANTON
State	:	MS
Zip	:	39046-8405
Country	:	US
Telephone Number	:	601-859-2906
Fax Number	:	601-859-0483

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	06/28/2012

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Directions to “ MR. TRENT LYDELL BUTLER PT” Practice Location

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