Provider Demographics
NPI:1265506497
Name:BOUTT, ANTHONY W (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:BOUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1522 PINE GROVE AVE
Mailing Address - Street 2:SUITE C
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
Practice Address - Street 2:SUITE C
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
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070173208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0740213OtherBCBS
H66438OtherHAP
134086OtherCARE CHOICE
7115359OtherAETNA
MIG46300005Medicare ID - Type Unspecified
134086OtherCARE CHOICE