Provider Demographics
NPI:1730172297
Name:BUTCHER, PAMELA S (DO)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 KANAWHA AVE
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1013
Mailing Address - Country:US
Mailing Address - Phone:304-438-6188
Mailing Address - Fax:304-438-6819
Practice Address - Street 1:645 KANAWHA AVE
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1013
Practice Address - Country:US
Practice Address - Phone:304-438-6188
Practice Address - Fax:304-438-6819
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7652215OtherAETNA
WVH22519OtherTRICARE
WV1713064OtherBC/BS
WV1802427000Medicaid
WV80190394OtherRR MEDICARE
WV1713064OtherBC/BS
WVH22519OtherTRICARE
H22519Medicare UPIN