Provider Demographics
NPI:1982816633
Name:SAMIR B.G. BOUTROS, M.D.P.C.
Entity Type:Organization
Organization Name:SAMIR B.G. BOUTROS, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOUTORS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-447-3315
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0025
Mailing Address - Country:US
Mailing Address - Phone:434-447-3315
Mailing Address - Fax:434-447-2540
Practice Address - Street 1:420 DURANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1614
Practice Address - Country:US
Practice Address - Phone:434-447-3315
Practice Address - Fax:434-447-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032398174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACH0681Medicare PIN
VA0397640001Medicare NSC
VAC05775Medicare PIN