Basic Information
Provider Information | |||||||||
NPI: | 1811948490 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOUTIN | ||||||||
FirstName: | PIER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 725 NORTH ST | ||||||||
Address2: |   | ||||||||
City: | PITTSFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 012014109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4134472752 | ||||||||
FaxNumber: | 4134966836 | ||||||||
Practice Location | |||||||||
Address1: | 27 LEWIS AVE | ||||||||
Address2: | ORTHOPEDICS AND SPORTS MEDICINE OF FAIRVIEW HOSPITAL | ||||||||
City: | GT BARRINGTON | ||||||||
State: | MA | ||||||||
PostalCode: | 012302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4138549753 | ||||||||
FaxNumber: | 4138549732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 01/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 216742 | MA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2029642 | 01 | MA | MASS HEALTH NUMBER | OTHER |