Basic Information
| Provider Information | |||||||||
| NPI: | 1508856071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTWELL | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SERRA | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD FAAP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7816819901 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 154226 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 042297845 | 01 | MA | UNITED HEALTH CARE | OTHER | 154227 | 01 | MA | TUFTS MEDICARE PREFERRED | OTHER | 5303578 | 01 | MA | AETNA | OTHER | 154227 | 01 | TUFTS - HMO | OTHER | 6030047 | 01 | MA | CIGNA | OTHER | J17820 | 01 | MA | BCBS | OTHER | 201609 | 01 | MA | HVD PILGRIM HEALTH CARE | OTHER | 0016419 | 01 | MA | NEIGHBORHOOD HLTH PLAN | OTHER | 042297845 | 01 | MA | GIC UNICARE | OTHER | 34696 | 01 | MA | FALLON | OTHER | 042297845 | 01 | MA | HCVM | OTHER | 042297845 | 01 | MA | PRIVATE HEALTHCARE SYSTEM | OTHER | 3168531 | 05 | MA | MEDICAID | 042297845 | 01 | MA | TRICARE | OTHER | 154227 | 01 | MA | TUFTS | OTHER |