Provider Demographics
NPI:1013928621
Name:BOUTON, R CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:R CHRISTOPHER
Middle Name:
Last Name:BOUTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S JAMES ST
Mailing Address - Street 2:BOUTON PHYSICAL THERAPY
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440
Mailing Address - Country:US
Mailing Address - Phone:315-337-1436
Mailing Address - Fax:315-337-1437
Practice Address - Street 1:221 S JAMES ST
Practice Address - Street 2:BOUTON PHYSICAL THERAPY
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-337-1436
Practice Address - Fax:315-337-1437
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0143541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
04102500062OtherFIDELIS
6699194OtherGHI
10058323OtherCDPHP
7164110OtherAETNA
NY02071589Medicaid
435054OtherMVP
6699194OtherGHI