1023454204 NPI number — MARYSE BOUCHARD M.D.

Table of content: MARYSE BOUCHARD M.D. (NPI 1023454204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023454204 NPI number — MARYSE BOUCHARD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHARD
Provider First Name:
MARYSE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023454204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5371
Provider Second Line Business Mailing Address:
4800 SANDPOINT WAY NE, W-7706
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98105-0371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-987-0104
Provider Business Mailing Address Fax Number:
206-987-3852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 SAND POINT WAY NE
Provider Second Line Business Practice Location Address:
W-7706
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98105-0371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-987-0104
Provider Business Practice Location Address Fax Number:
206-987-3852
Provider Enumeration Date:
05/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XP3100X , with the licence number:  60349185 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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