Provider Demographics
NPI:1043210818
Name:BOUTELL, MATTHEW JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:BOUTELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2680 LEONARD ST NE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-949-9944
Mailing Address - Fax:616-949-4978
Practice Address - Street 1:2680 LEONARD ST. NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-224-1515
Practice Address - Fax:616-224-2070
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2018-09-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301081178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G711119Medicare UPIN