Provider Demographics
NPI:1811044167
Name:BOUTON, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:BOUTON
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 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:440-684-5829
Mailing Address - Fax:440-449-1555
Practice Address - Street 1:11000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1714
Practice Address - Country:US
Practice Address - Phone:440-684-5829
Practice Address - Fax:440-449-1555
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0847342080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000337118OtherANTHEM
OH732324OtherBUCKEYE
OH000000221061OtherUNISON
OH363374OtherWELLCARE
OH7288591OtherAETNA
OH2502410OtherBCMH
OH2502410Medicaid
PA1011138340001OtherPA MEDICAID
OHP00412306OtherRAILROAD MEDICARE
OH000000337118OtherANTHEM
OHP00412306OtherRAILROAD MEDICARE
OHBO4143675Medicare PIN