Basic Information
| Provider Information | |||||||||
| NPI: | 1184723819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHASSIBI | ||||||||
| FirstName: | BOUTROS | ||||||||
| MiddleName: | MICHEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 HAVERHILL ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018412884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786860090 | ||||||||
| FaxNumber: | 9786815963 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 HAVERHILL ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018412884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786860090 | ||||||||
| FaxNumber: | 9786815963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 72138 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207QS0010X | 72138 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3166724 | 05 | MA | MEDICAID |