1174598510 NPI number — DR. MARTIN J BOUCHER MD

Table of content: DR. MARTIN J BOUCHER MD (NPI 1174598510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174598510 NPI number — DR. MARTIN J BOUCHER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHER
Provider First Name:
MARTIN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1174598510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46 BLUEBERRY HL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOLFEBORO
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03894-4526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-569-6323
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 BLUEBERRY HL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOLFEBORO
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03894-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-569-6323
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2006

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: 207P00000X , with the licence number:  8070 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 8070 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 383833 . This is a "MVP" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: E68456 . This is a "HARVARD PILGRIM HLTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0107072Y0NH01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 3422723 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30002969 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9692314 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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