Provider Demographics
NPI:1346362423
Name:BOUTROUS, ATTAS II (MD)
Entity type:Individual
Prefix:
First Name:ATTAS
Middle Name:
Last Name:BOUTROUS
Suffix:II
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 1:202 E GREENFIELD LN STE 100
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-6597
Mailing Address - Country:US
Mailing Address - Phone:701-223-7822
Mailing Address - Fax:701-223-7844
Practice Address - Street 1:202 E GREENFIELD LN STE 100
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-6597
Practice Address - Country:US
Practice Address - Phone:701-223-7822
Practice Address - Fax:701-223-7844
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6635207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1462491Medicaid
SD5700930Medicaid
MT0040053Medicaid
MN3537218-00Medicaid
SD5700930Medicaid
ND17608Medicaid
NDF61290Medicare UPIN