Healthcare Provider Details

I. General information

NPI: 1346568110
Provider Name (Legal Business Name): STEVEN P BOUTRUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 COURT ST
KEENE NH
03431-1718
US

IV. Provider business mailing address

580 COURT ST
KEENE NH
03431-1718
US

V. Phone/Fax

Practice location:
  • Phone: 603-354-5454
  • Fax:
Mailing address:
  • Phone: 603-354-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number16029
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3087917
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: