Healthcare Provider Details

I. General information

NPI: 1922030808
Provider Name (Legal Business Name): MICHAEL J BOUCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MOBILE INFIRMARY CIR
MOBILE AL
36607-3513
US

IV. Provider business mailing address

PO BOX 10583
BIRMINGHAM AL
35202-0583
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-2646
  • Fax: 251-435-6478
Mailing address:
  • Phone: 251-435-2646
  • Fax: 251-435-6478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number16746
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.16746
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: