1316098361 NPI number — DR. KENNETH R BOUCHARD PH.D.

Table of content: DR. KENNETH R BOUCHARD PH.D. (NPI 1316098361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316098361 NPI number — DR. KENNETH R BOUCHARD PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHARD
Provider First Name:
KENNETH
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1316098361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32411 BRIARCREST KNLS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-1515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-505-1689
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6777 WEST MAPLE ROAD
Provider Second Line Business Practice Location Address:
OTOLARYNGOLOGY/AUDIOLOGY HENRY FORD W.BLOOMFILED HOSP
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-925-8276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2007

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: 237600000X , with the licence number:  1601000335 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1601000335 . This is a "AUDIOLOGIST LICENSE STATE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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