1679771646 NPI number — CHARLES A BOUCHER MD PC

Table of content: (NPI 1679771646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679771646 NPI number — CHARLES A BOUCHER MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES A BOUCHER MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1679771646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02205-1512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-726-8511
Provider Business Mailing Address Fax Number:
617-742-8446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 HAWTHORNE PL
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-726-8511
Provider Business Practice Location Address Fax Number:
617-742-8446
Provider Enumeration Date:
07/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOUCHER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
617-726-8511

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  36588 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 36588 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 705823 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9738193 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M13371 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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