MEDICARE: JEREMY MICHAEL BOUCHER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	23387	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093853053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY MICHAEL BOUCHER MD

Provider Business Mailing Address
First Line	:	11520 HAVEN WAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-4616
Country	:	US
Telephone Number	:	405-881-7776
Fax Number	:

Provider Business Practice Location Address
First Line	:	11520 HAVEN WAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-4616
Country	:	US
Telephone Number	:	405-881-7776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	11/20/2020

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