MEDICARE: MATTHEW L BOULTON MD, MPH

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	2083P0901X	Public Health & General Preventive Medicine Physician	5315116585	MI

General Provider Information

NPI Number	:	1497315477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW L BOULTON MD, MPH

Provider Business Mailing Address
First Line	:	1415 WASHINGTON HTS
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48109-2029
Country	:	US
Telephone Number	:	734-936-1623
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 WASHINGTON HTS
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48109-2029
Country	:	US
Telephone Number	:	734-936-1623
Fax Number	:

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

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	06/20/2019

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