MEDICARE: SOUTHERN PINES FAMILY MEDICAL

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245326149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PINES FAMILY MEDICAL

Provider Business Mailing Address
First Line	:	PO BOX 1659
Second Line	:
City	:	PEARL RIVER
State	:	LA
Zip	:	70452-1659
Country	:	US
Telephone Number	:	985-863-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	64629 HIGHWAY 41
Second Line	:
City	:	PEARL RIVER
State	:	LA
Zip	:	70452-3611
Country	:	US
Telephone Number	:	985-863-7100
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. GLENN BUTT
Credential	:	M D
Telephone Number	:	985-863-7100

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	06/08/2011

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Directions to “SOUTHERN PINES FAMILY MEDICAL ” Practice Location

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