Healthcare Provider Details

I. General information

NPI: 1316908809
Provider Name (Legal Business Name): WALTER CLARK BOUTWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HUNTER TRL
PIKE ROAD AL
36064-3415
US

IV. Provider business mailing address

207 HUNTER TRL
PIKE ROAD AL
36064-3415
US

V. Phone/Fax

Practice location:
  • Phone: 334-657-7198
  • Fax: 334-272-4876
Mailing address:
  • Phone: 334-657-7198
  • Fax: 334-272-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD-014439-E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: