Provider Demographics
NPI:1710981071
Name:BOUTT, ANTHONY EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:EDWARD
Last Name:BOUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15990 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:408
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-465-4470
Practice Address - Fax:248-465-4471
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030028207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI333564110Medicaid
MI0F36022006Medicare ID - Type UnspecifiedPROVIDER ID
MI333564110Medicaid