1083664239 NPI number — CAROLE BOUDREAUX MD

Table of content: CAROLE BOUDREAUX MD (NPI 1083664239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083664239 NPI number — CAROLE BOUDREAUX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX
Provider First Name:
CAROLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083664239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40480
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36640-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-471-7790
Provider Business Mailing Address Fax Number:
251-471-7715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 FILLINGIM ST
Provider Second Line Business Practice Location Address:
PATHOLOGY
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36617-2238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-471-7790
Provider Business Practice Location Address Fax Number:
251-471-7715
Provider Enumeration Date:
05/10/2006

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: 207ZC0500X , with the licence number:  16509 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 16509 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00118221 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1523593 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51024061 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 11-10270 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000024061 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 255587500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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