MEDICARE: PHILIP CHARLES BOULANGER

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	208D00000X	General Practice Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	190001514	OTHER	VA	MEDICARE GROUP#

General Provider Information

NPI Number	:	1144429564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILIP CHARLES BOULANGER

Provider Business Mailing Address
First Line	:	9401 FERNLEIGH DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23235-1311
Country	:	US
Telephone Number	:	804-389-2606
Fax Number	:	804-747-0643

Provider Business Practice Location Address
First Line	:	9401 FERNLEIGH DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23235-1311
Country	:	US
Telephone Number	:	804-389-2606
Fax Number	:	804-747-0643

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	PHILIP CHARLES BOULANGER
Credential	:	M.D.
Telephone Number	:	804-389-2606

Provider Enumeration Date	:	07/16/2007
Last Update Date	:	06/26/2008

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