MEDICARE: HANNA BOUTROS SLIM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	278769	NY
2	207R00000X	Internal Medicine Physician	047628	CT
3	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417130410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNA BOUTROS SLIM M.D.

Provider Business Mailing Address
First Line	:	214 CORNELIA ST
Second Line	:	SUITE 102
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2317
Country	:	US
Telephone Number	:	518-561-6410
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 CORNELIA ST
Second Line	:	SUITE 102
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2317
Country	:	US
Telephone Number	:	518-561-6410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	01/21/2016

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