Healthcare Provider Details

I. General information

NPI: 1699769869
Provider Name (Legal Business Name): RENE ALBERT BOUCHER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 NATCHEZ TRACE AVE SUITE 205
BOWLING GREEN KY
42103-7940
US

IV. Provider business mailing address

350 PARK ST STE 203 B
BOWLING GREEN KY
42101-1784
US

V. Phone/Fax

Practice location:
  • Phone: 270-282-2024
  • Fax: 270-393-1913
Mailing address:
  • Phone: 270-393-1912
  • Fax: 270-393-1913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number02561
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number02561
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number02561
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number02561
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: