Basic Information
| Provider Information | |||||||||
| NPI: | 1710981071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTT | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15990 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488494226 | ||||||||
| FaxNumber: | 2488494240 | ||||||||
| Practice Location | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | 408 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654470 | ||||||||
| FaxNumber: | 2484654471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301030028 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 333564110 | 05 | MI | MEDICAID |