Logan Tyler Boutwell, MD

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

4500 13TH St
Gulfport, MS 39501-2515

Phone

(228) 867-4000

NPI assigned

May 13, 2024

Last updated

May 13, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MS

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1715558400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1715558400000",
    "number": "1649029729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "995 BAY SHORE DR",
            "city": "BILOXI",
            "state": "MS",
            "postal_code": "395301751",
            "telephone_number": "601-270-3388"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4500 13TH ST",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395012515",
            "telephone_number": "228-867-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOUTWELL",
        "first_name": "LOGAN",
        "middle_name": "TYLER",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-05-13",
        "last_updated": "2024-05-13",
        "certification_date": "2024-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Chelsea Rae Bourgeois, RDN, LD, MS
• Kevin Raymond Bourgeois Jr., DO
• Kimberly Bourgeois
• Ronald S. Bourgeois, DDS
• Aurellia Celeste Bourne, RN, CLC
• Caleb Brennan Bowen, DO
• Bradley Boyd
• Jill Boyer
• Bozlee Physical Therapy LLC
• Elizabeth Z Bozlee, P.T.

• Student in an Organized Health Care Education/Training Program in Gulfport, MS
• Providers in Gulfport, MS by specialty
• Student in an Organized Health Care Education/Training Program in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.