Provider Demographics
NPI:1568451615
Name:MICHAEL, AMANI BOULOS (MD)
Entity Type:Individual
Prefix:
First Name:AMANI
Middle Name:BOULOS
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 PHEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2650
Mailing Address - Country:US
Mailing Address - Phone:781-363-5801
Mailing Address - Fax:781-828-1106
Practice Address - Street 1:2 PHEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2650
Practice Address - Country:US
Practice Address - Phone:781-363-5801
Practice Address - Fax:781-828-1106
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1611062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2023377Medicaid
MAMI A32060Medicare ID - Type Unspecified
MA2023377Medicaid
MAA3934001Medicare UPIN