MEDICARE: NIHAD M BOUTROS 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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	35-065732	OH
2	207RP1001X	Pulmonary Disease Physician	35-065732	OH
3	207RS0012X	Sleep Medicine (Internal Medicine) Physician	35-065732	OH

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
2	341574729F	OTHER	OH	AULTCARE
3	733560	OTHER	OH	BUCKEYE COMMUNITY HEALTH
4	000000186380	OTHER	OH	UNISON HEALTH PLAN
5	000000283988	OTHER	OH	ANTHEM BC/BS
6	341574729036	OTHER	OH	CARESOURCE
7	Q035419	OTHER	OH	THE HEALTH PLAN

General Provider Information

NPI Number	:	1508869454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIHAD M BOUTROS M.D.

Provider Business Mailing Address
First Line	:	2600 TUSCARAWAS ST W
Second Line	:	STE 100
City	:	CANTON
State	:	OH
Zip	:	44708-4696
Country	:	US
Telephone Number	:	330-452-8844
Fax Number	:	330-452-7012

Provider Business Practice Location Address
First Line	:	2600 TUSCARAWAS ST W
Second Line	:	STE 100
City	:	CANTON
State	:	OH
Zip	:	44708-4696
Country	:	US
Telephone Number	:	330-452-8844
Fax Number	:	330-452-7012

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	01/05/2011

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Directions to “ NIHAD M BOUTROS M.D.” Practice Location

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