Provider Demographics
NPI:1346568110
Name:BOUTRUS, STEVEN P (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:P
Last Name:BOUTRUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1718
Mailing Address - Country:US
Mailing Address - Phone:603-354-5454
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1718
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16029207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3087917Medicaid
NH003407501Medicare PIN