Basic Information
Provider Information | |||||||||
NPI: | 1912105495 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOUTROS | ||||||||
FirstName: | CHERIF | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GLEN BURNIE | ||||||||
State: | MD | ||||||||
PostalCode: | 210615803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107874594 | ||||||||
FaxNumber: | 4107874846 | ||||||||
Practice Location | |||||||||
Address1: | 305 HOSPITAL DRIVE | ||||||||
Address2: | TATE CENTER | ||||||||
City: | GLEN BURNIE | ||||||||
State: | MD | ||||||||
PostalCode: | 21061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105538146 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2007 | ||||||||
LastUpdateDate: | 10/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | D0070965 | MD | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
ID | Type | State | Issuer | Description | GROUP PTAN:DQ7486 | 01 | MD | MEDICARE RAIL ROAD | OTHER | Q818-0022 | 01 | MD | CAREFIRST GROUP | OTHER | 238612 | 01 | MD | JOHNS HOPKINS HEALTHCARE | OTHER | 967368-02 | 01 | MD | CAREFIRST RENDERING NUMBER | OTHER | 034615200 | 05 | MD |   | MEDICAID | P00893238 | 01 | MD | MEDICARE RAIL ROAD | OTHER |