Individual
MIREILLE N BOUTRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
11100 EUCLID AVE, CLEVELAND, OH 44106-1716
(216) 844-7700
(216) 286-6341
Mailing address
24701 EUCLID AVE, 3RD FLOOR, EUCLID, OH 44117-1714
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
35-060531
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000027989
ANTHEM
OH
01
—
000000220998
UNISON
OH
01
—
000000525909
ANTHEM
OH
01
—
0635168
AETNA
OH
01
—
0822695
BCMH
OH
05
—
0822695
—
OH
01
—
1011820810001
PA MEDICAID
PA
01
—
363375
WELLCARE
OH
01
—
370001902
RAILROAD MEDICARE
OH
01
—
738036
BUCKEYE
OH
Enumeration date
07/18/2006
Last updated
06/30/2011
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