Provider Demographics
NPI:1922046317
Name:BOUTWELL, CHRISTINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:M
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MAILSTOP 400
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-599-9499
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4400 BROADWAY
Practice Address - Street 2:SUITE 520
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3342
Practice Address - Country:US
Practice Address - Phone:816-531-4080
Practice Address - Fax:816-531-0281
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-286642084N0400X
MO1034752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
130021444Medicare PIN
MOC997452AMedicare PIN
F93721Medicare UPIN
MOC997452Medicare PIN
5353198OtherAETNA
F93721Medicare UPIN
KS100192400BMedicaid
MOC997452Medicare PIN