=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174820518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JOSEPH BOUCHARD D.P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2011
-----------------------------------------------------
Last Update Date | 02/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 STATE ST SUITE #610
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-947-8381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 AIRPORT RD
-----------------------------------------------------
City | ENFIELD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04493-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-659-2258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT3456
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------