Provider Demographics
NPI:1013946094
Name:BOUTSELIS, MAXIMINA (MD)
Entity Type:Individual
Prefix:
First Name:MAXIMINA
Middle Name:
Last Name:BOUTSELIS
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 1:20 FOLLINSBEE LANE
Mailing Address - Street 2:
Mailing Address - City:WEST NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01985-4201
Mailing Address - Country:US
Mailing Address - Phone:888-886-5238
Mailing Address - Fax:888-886-9330
Practice Address - Street 1:20 FOLLINSBEE LN
Practice Address - Street 2:
Practice Address - City:WEST NEWBURY
Practice Address - State:MA
Practice Address - Zip Code:01985-4201
Practice Address - Country:US
Practice Address - Phone:978-761-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156198208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30200844Medicaid
MA0101290Medicaid
H21856Medicare UPIN
H21856Medicare UPIN