Provider Demographics
NPI:1508869454
Name:BOUTROS, NIHAD M (MD)
Entity Type:Individual
Prefix:
First Name:NIHAD
Middle Name:M
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 TUSCARAWAS ST W
Mailing Address - Street 2:STE 100
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4696
Mailing Address - Country:US
Mailing Address - Phone:330-452-8844
Mailing Address - Fax:330-452-7012
Practice Address - Street 1:2600 TUSCARAWAS ST W
Practice Address - Street 2:STE 100
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4696
Practice Address - Country:US
Practice Address - Phone:330-452-8844
Practice Address - Fax:330-452-7012
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-065732207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2401672Medicaid
OH341574729FOtherAULTCARE
OH733560OtherBUCKEYE COMMUNITY HEALTH
OH000000186380OtherUNISON HEALTH PLAN
OH000000283988OtherANTHEM BC/BS
OH341574729036OtherCARESOURCE
OHQ035419OtherTHE HEALTH PLAN
OH341574729036OtherCARESOURCE
OH000000186380OtherUNISON HEALTH PLAN
OH2401672Medicaid