Healthcare Provider Details

I. General information

NPI: 1629036173
Provider Name (Legal Business Name): DR. NIDAL BOUTROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 02/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HOSPITAL DR SUITE 300
LEBANON MO
65536-9238
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6746
  • Fax: 417-533-6740
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009027847
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: