MEDICARE: ANTHONY EDWARD BOUTT 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	207V00000X	Obstetrics & Gynecology Physician	4301030028	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

General Provider Information

NPI Number	:	1710981071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY EDWARD BOUTT MD

Provider Business Mailing Address
First Line	:	15990 W 9 MILE RD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-4826
Country	:	US
Telephone Number	:	248-849-4226
Fax Number	:	248-849-4240

Provider Business Practice Location Address
First Line	:	22250 PROVIDENCE DR
Second Line	:	408
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-4825
Country	:	US
Telephone Number	:	248-465-4470
Fax Number	:	248-465-4471

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

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	12/19/2011

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