Healthcare Provider Details

I. General information

NPI: 1083685366
Provider Name (Legal Business Name): PHILIP C BOULANGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 W BROAD ST
RICHMOND VA
23230-2219
US

IV. Provider business mailing address

1891 VIRGINIA AVE
HARRISONBURG VA
22802-8374
US

V. Phone/Fax

Practice location:
  • Phone: 804-213-0259
  • Fax:
Mailing address:
  • Phone: 804-389-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057867
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101057867
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: