MEDICARE: CHAD RYAN BOUTERSE D.O.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	5101016467	MI
2	207W00000X	Ophthalmology Physician	OP60127012	WA
3	207W00000X	Ophthalmology Physician	O 570	ID

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0080BO	OTHER		ASURIS - CLARKSTON
2	1699896167	OTHER		FEDERAL BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	258958	OTHER	WA	WASHINGTON LABOR & INDUSTRY
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1699896167	OTHER		PREMERA BLUE CROSS
7	0081BO	OTHER		ASURIS - PULLMAN
8	O 0570	OTHER	ID	STATE LICENSE
9	OP60127012	OTHER	WA	STATE LICENSE
10	1699896167	OTHER		REGENCE BLUE SHIELD
11	1699896167	OTHER		BLUE CROSS OF IDAHO
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1699896167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD RYAN BOUTERSE D.O.

Provider Business Mailing Address
First Line	:	500 PORT DR
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-1835
Country	:	US
Telephone Number	:	509-758-8811
Fax Number	:	509-751-1188

Provider Business Practice Location Address
First Line	:	500 PORT DR
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-1835
Country	:	US
Telephone Number	:	509-758-8811
Fax Number	:	509-751-1188

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	05/28/2010