Provider Demographics
NPI:1679771646
Name:CHARLES A BOUCHER MD PC
Entity type:Organization
Organization Name:CHARLES A BOUCHER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-726-8511
Mailing Address - Street 1:PO BOX 51512
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02205-1512
Mailing Address - Country:US
Mailing Address - Phone:617-726-8511
Mailing Address - Fax:617-742-8446
Practice Address - Street 1:8 HAWTHORNE PL
Practice Address - Street 2:SUITE 110
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2335
Practice Address - Country:US
Practice Address - Phone:617-726-8511
Practice Address - Fax:617-742-8446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36588207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA705823OtherTUFTS HEALTH PLAN
MA9738193Medicaid
MAM13371OtherBLUE CROSS BLUE SHIELD OF
MA705823OtherTUFTS HEALTH PLAN