MEDICARE: PAUL D. BOUTIN MD

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	2084P0804X	Child & Adolescent Psychiatry Physician	042.0011364	VT
2	2084P0804X	Child & Adolescent Psychiatry Physician	042 0011364	VT

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689787673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL D. BOUTIN MD

Provider Business Mailing Address
First Line	:	390 RIVER STREET
Second Line	:
City	:	SPRINGFIELD
State	:	VT
Zip	:	05156-2226
Country	:	US
Telephone Number	:	802-886-4500
Fax Number	:	802-886-4520

Provider Business Practice Location Address
First Line	:	51 FAIRVIEW STREET
Second Line	:
City	:	BRATTLEBORO
State	:	VT
Zip	:	05301-6629
Country	:	US
Telephone Number	:	802-254-6028
Fax Number	:	802-254-7501

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	11/27/2019

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Directions to “ PAUL D. BOUTIN MD” Practice Location

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