Healthcare Provider Details

I. General information

NPI: 1487911038
Provider Name (Legal Business Name): HAROLD JOSEPH BOUTTE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HAL JOSPEH BOUTTE JR. M.D.

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 1600
CHICAGO IL
60611-3111
US

IV. Provider business mailing address

259 E ERIE ST STE 1600
CHICAGO IL
60611-3111
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5620
  • Fax:
Mailing address:
  • Phone: 312-695-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036145207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: