Provider Demographics
NPI:1932127750
Name:BOUTRY, MIREILLE N (MD)
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:N
Last Name:BOUTRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-060531208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000220998OtherUNISON
OH000000525909OtherANTHEM
OH0635168OtherAETNA
OH0822695Medicaid
OH363375OtherWELLCARE
OH738036OtherBUCKEYE
OH000000027989OtherANTHEM
OH0822695OtherBCMH
OH370001902OtherRAILROAD MEDICARE
PA1011820810001OtherPA MEDICAID
OH000000027989OtherANTHEM
OH000000525909OtherANTHEM
OHBO4126494Medicare PIN