NPIMap

Individual provider Active NPI

Nidal Boutros

  • Internal Medicine Physician
  • Lebanon, MO
National Provider Identifier
1629036173
Registry record updated Feb 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
2009027847 Issued in MO
Practice address
120 Hospital Dr
Suite 300
Lebanon, MO 65536-9238
Phone
(417) 533-6746
Fax
(417) 533-6740
NPI assigned
May 3, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 10, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 2009027847 MO Primary

Addresses

Primary practice location

120 Hospital Dr
Suite 300
Lebanon, MO 65536-9238

Mailing address

PO Box 505164
Saint Louis, MO 63150-5164
Phone (417) 829-4620

Other identifiers 1

IdentifierTypeStateIssuer
1629036173MedicaidMO

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address NIDAL.BOUTROS@hca2.eclinicaldirectplus.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KS
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20170118000701 KS Practitioner - Internal Medicine 0941303945 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Other, 1990
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Statland Medical Group LLCGroup PAC ID 0042335044, 4 clinicians

Practice addresses (Care Compare)

12140 Nall Ave
Suite 100
Overland Park, KS 66209-2504
Phone (816) 943-0706

5701 W 119TH St
Suite 330
Overland Park, KS 66209-3754
Phone (913) 345-8500

5721 W 119TH St
Menorah Medical Center
Overland Park, KS 66209-3722
Phone (913) 498-6000

Hospital & facility affiliations

  • HCA Midwest Healthcare at Home Home health agency, Kansas City, MO, CCN 267609
  • Adventhealth Home Health Home health agency, Shawnee Mission, KS, CCN 178058
  • Menorah Medical Center Hospital, Overland Park, KS, CCN 170182
  • Overland Park Reg Med Ctr Hospital, Overland Park, KS, CCN 170176
  • Saint Luke'S South Hospital Hospital, Overland Park, KS, CCN 170185
  • University of Kansas Hospital Hospital, Kansas City, KS, CCN 170040
  • Belton Regional Medical Center Hospital, Belton, MO, CCN 260214
  • Village Shalom Inc Nursing home, Overland Park, KS, CCN 175441

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Statland Clinic LTD Internal Medicine Past Accepting new patients

Interoperability endpoints

  • Direct secure messaging: nboutros121319@directb.mercy.net

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146614400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1644451200000",
    "number": "1629036173",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 505164",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631505164",
            "telephone_number": "417-829-4620"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 HOSPITAL DR",
            "address_2": "SUITE 300",
            "city": "LEBANON",
            "state": "MO",
            "postal_code": "655369238",
            "telephone_number": "417-533-6746",
            "fax_number": "417-533-6740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOUTROS",
        "first_name": "NIDAL",
        "name_prefix": "Dr.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-03",
        "last_updated": "2022-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MO",
            "license": "2009027847",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1629036173",
            "state": "MO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "NIDAL.BOUTROS@hca2.eclinicaldirectplus.com",
            "affiliation": "N",
            "address_1": "120 Hospital Dr",
            "address_2": "SUITE 300",
            "city": "Lebanon",
            "state": "MO",
            "country_code": "US",
            "postal_code": "655369238",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Lebanon, MO

Sources for this page

Verify at the official NPI Registry.