Provider Demographics
NPI:1720325574
Name:JACQUELINE BOUTROUILLE MD PA
Entity Type:Organization
Organization Name:JACQUELINE BOUTROUILLE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOUTROUILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-340-3000
Mailing Address - Street 1:7880 N UNIVERSITY DR
Mailing Address - Street 2:STE 303
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2124
Mailing Address - Country:US
Mailing Address - Phone:954-340-3000
Mailing Address - Fax:954-636-8407
Practice Address - Street 1:7880 N UNIVERSITY DR
Practice Address - Street 2:STE 303
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2124
Practice Address - Country:US
Practice Address - Phone:954-340-3000
Practice Address - Fax:954-636-8407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME870292084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268083100Medicaid
FLK1643Medicare PIN
FL268083100Medicaid