Provider Demographics
NPI:1740262039
Name:BOUTIN, ARLENE (MD)
Entity type:Individual
Prefix:
First Name:ARLENE
Middle Name:
Last Name:BOUTIN
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 1:2497 7TH AVE E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2496
Mailing Address - Country:US
Mailing Address - Phone:651-769-6437
Mailing Address - Fax:651-769-6426
Practice Address - Street 1:2497 7TH AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-2496
Practice Address - Country:US
Practice Address - Phone:651-769-6400
Practice Address - Fax:651-769-6449
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02173012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4F004B0OtherBCBS OF MN
MN1553870OtherMEDICA
A95591Medicare UPIN