Basic Information
| Provider Information | |||||||||
| NPI: | 1962493676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTROS | ||||||||
| FirstName: | NABIL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE VANTAGE WAY | ||||||||
| Address2: | SUITE B-240 MIDDLE TENNESSEE EMERGENCY PHYSICIANS, PC | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 272281562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294020 | ||||||||
| FaxNumber: | 6153299479 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N. HIGHLAND AVE | ||||||||
| Address2: | MIDDLE TENNESSEE MEDICAL CENTER | ||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002512014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 07/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 32688 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 41834 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 453051001 | 01 | AZ | GROUP HEALTH GRP | OTHER | 860373636 | 01 | AZ | HUMANA GROUP | OTHER | 892150 | 05 | AZ | MEDICAID | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD GR | OTHER | 3981220 | 01 | AZ | EVERCARE GRP | OTHER | AW1436 | 01 | AZ | HEALTHNET GRP | OTHER |