Provider Demographics
NPI:1073939732
Name:ANTHONY W BOUTT MD PC
Entity Type:Organization
Organization Name:ANTHONY W BOUTT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-987-3556
Mailing Address - Street 1:1522 PINE GROVE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3382
Mailing Address - Country:US
Mailing Address - Phone:810-987-3556
Mailing Address - Fax:810-987-5090
Practice Address - Street 1:1522 PINE GROVE AVE STE C
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3382
Practice Address - Country:US
Practice Address - Phone:810-987-3556
Practice Address - Fax:810-987-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070173208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty