Healthcare Provider Details

I. General information

NPI: 1669460051
Provider Name (Legal Business Name): PHILIP JOSEPH BOLDUC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 QUEEN ST FAMILY PRACTICE 3
WORCESTER MA
01610-2473
US

IV. Provider business mailing address

26 QUEEN ST
WORCESTER MA
01610-2473
US

V. Phone/Fax

Practice location:
  • Phone: 508-860-7700
  • Fax: 508-860-7929
Mailing address:
  • Phone: 508-860-7700
  • Fax: 508-860-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number223110
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: