Healthcare Provider Details

I. General information

NPI: 1043203318
Provider Name (Legal Business Name): T. GLEN BOUDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 AMHERST ST
WINCHESTER VA
22601-2808
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2896
US

V. Phone/Fax

Practice location:
  • Phone: 540-536-8874
  • Fax: 540-536-7847
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD051542L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101244705
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: