Basic Information
| Provider Information | |||||||||
| NPI: | 1811044167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406845829 | ||||||||
| FaxNumber: | 4404491555 | ||||||||
| Practice Location | |||||||||
| Address1: | 11000 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406845829 | ||||||||
| FaxNumber: | 4404491555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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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 | 2080P0204X | 35-084734 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000337118 | 01 | OH | ANTHEM | OTHER | 732324 | 01 | OH | BUCKEYE | OTHER | 000000221061 | 01 | OH | UNISON | OTHER | 363374 | 01 | OH | WELLCARE | OTHER | 7288591 | 01 | OH | AETNA | OTHER | 2502410 | 01 | OH | BCMH | OTHER | 2502410 | 05 | OH | MEDICAID | 1011138340001 | 01 | PA | PA MEDICAID | OTHER | P00412306 | 01 | OH | RAILROAD MEDICARE | OTHER |