Provider Demographics
NPI:1487619722
Name:BOUTROUS, JAMES J (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:BOUTROUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:20952 E 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3200
Practice Address - Country:US
Practice Address - Phone:586-771-4820
Practice Address - Fax:586-771-6620
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028307208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101289OtherPRIORITY HEALTH
MI4522258OtherAETNA
MIA75907OtherHAP
MI340017814OtherRAILROAD MEDICARE
MI2406964001OtherCIGNA
MI0E06273002Medicare PIN
MI2406964001OtherCIGNA
MI4522258OtherAETNA