1285749549 NPI number — DR. JULIE A BOUTT M.D.

Table of content: DR. JULIE A BOUTT M.D. (NPI 1285749549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285749549 NPI number — DR. JULIE A BOUTT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTT
Provider First Name:
JULIE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285749549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4071 24TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GRATIOT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48059-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-824-4222
Provider Business Mailing Address Fax Number:
810-824-4220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4071 24TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT GRATIOT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48059-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-824-4222
Provider Business Practice Location Address Fax Number:
810-824-4220
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  JB070145 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1285749549 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383662851 . This is a "PPOM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4643528 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0807410461 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 9153443002 . This is a "CIGNA HEALTHCARE HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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