Healthcare Provider Details

I. General information

NPI: 1508856071
Provider Name (Legal Business Name): GINA S. BOUTWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA MARIE SERRA MD FAAP

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LONGWATER DR FL 2
NORWELL MA
02061-1639
US

IV. Provider business mailing address

600 LONGWATER DR FL 2
NORWELL MA
02061-1639
US

V. Phone/Fax

Practice location:
  • Phone: 781-745-3322
  • Fax: 781-561-0610
Mailing address:
  • Phone: 781-745-3322
  • Fax: 781-561-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number154226
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: