MEDICARE: DR. JULIE A BOUTT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	JB070145	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	383662851	OTHER	MI	PPOM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0807410461	OTHER	MI	BLUE CROSS/BLUE SHIELD
5	9153443002	OTHER	MI	CIGNA HEALTHCARE HMO

General Provider Information

NPI Number	:	1285749549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIE A BOUTT M.D.

Provider Business Mailing Address
First Line	:	3041 COMMERCE DR STE B
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3877
Country	:	US
Telephone Number	:	810-432-0500
Fax Number	:	810-432-0501

Provider Business Practice Location Address
First Line	:	3041 COMMERCE DR STE B
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3877
Country	:	US
Telephone Number	:	810-432-0500
Fax Number	:	810-432-0501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	03/19/2026

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