Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 085-003282 | IL |
NPI | 1033369343 |
---|---|
Provider Name | Mr. Joseph Thomas Boutet |
First Address | Chicago, IL 60611-5975 |
Second Address | Chicago, IL 60611-3926 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/09/2008 |
Last Update Date | 08/01/2018 |