MEDICARE: KARI BOUCHER M.D.

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	207N00000X	Dermatology Physician	MD417529	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1438394	OTHER	PA	BLUE SHIELD
2	2122596000	OTHER	PA	IBC

General Provider Information

NPI Number	:	1336225481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARI BOUCHER M.D.

Provider Business Mailing Address
First Line	:	500 EVERGREEN DR
Second Line	:	SUITE 20
City	:	GLEN MILLS
State	:	PA
Zip	:	19342-1032
Country	:	US
Telephone Number	:	484-785-3376
Fax Number	:	610-358-6913

Provider Business Practice Location Address
First Line	:	500 EVERGREEN DR
Second Line	:	SUITE 20
City	:	GLEN MILLS
State	:	PA
Zip	:	19342-1032
Country	:	US
Telephone Number	:	484-785-3376
Fax Number	:	610-358-6913

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	09/09/2014

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Directions to “ KARI BOUCHER M.D.” Practice Location

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