Healthcare Provider Details

I. General information

NPI: 1194083675
Provider Name (Legal Business Name): ALEXANDER ALBERT BOUCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 03/08/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number57181
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: