Provider Demographics
NPI:1861579666
Name:BUTNER, TARRY ADAIR (PT)
Entity type:Individual
Prefix:
First Name:TARRY
Middle Name:ADAIR
Last Name:BUTNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13141 GARRETT HWY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1164
Mailing Address - Country:US
Mailing Address - Phone:301-334-5220
Mailing Address - Fax:301-334-6277
Practice Address - Street 1:13141 GARRETT HWY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1164
Practice Address - Country:US
Practice Address - Phone:301-334-5220
Practice Address - Fax:301-334-6277
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE273 0003OtherGHMSI & BCBS FEERAL
WV0158028000Medicaid
MDIWIF 25-99OtherINJURED WORKERS'
MD11937OtherPRIORITY PARTNERS
MD60405501OtherCAREFIRST BCBS
MD15636OtherLICENSE #
MD258607OtherALLIANCE/MD.IPA/OPTIMUM C
MDIWIF 25-99OtherINJURED WORKERS'