Provider Demographics
NPI:1780785428
Name:BUTLER, MICHAEL
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3226 HAMPTON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4225
Mailing Address - Country:US
Mailing Address - Phone:912-264-0760
Mailing Address - Fax:
Practice Address - Street 1:3226 HAMPTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4225
Practice Address - Country:US
Practice Address - Phone:912-264-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035833174400000X
GA35833207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060049391OtherRR MEDICARE
GA00791975AMedicaid
GAF64074Medicare UPIN