Provider Demographics
NPI:1255331708
Name:BOUTWELL, GARY EUGENE (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EUGENE
Last Name:BOUTWELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 10TH AVE S
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1200
Mailing Address - Country:US
Mailing Address - Phone:205-939-0139
Mailing Address - Fax:205-939-4997
Practice Address - Street 1:985 9TH AVE SW
Practice Address - Street 2:SUITE 403
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-4500
Practice Address - Country:US
Practice Address - Phone:205-481-8470
Practice Address - Fax:205-481-8473
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-092654363LA2100X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP67309Medicare UPIN
AL051528357Medicare ID - Type Unspecified