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NPI Code Detail

MEDICARE: T. GLEN BOUDER MD

MEDICARE: T. GLEN BOUDER MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207RP1001XPulmonary Disease PhysicianMD051542LPA
2207RC0200XCritical Care Medicine (Internal Medicine) Physician0101244705VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1043203318
Entity Type Code : Individual
Provider Name (Legal Business Name) : T. GLEN BOUDER MD
Provider Business Mailing Address
First Line : 220 CAMPUS BLVD STE 100
Second Line :
City : WINCHESTER
State : VA
Zip : 22601-2896
Country : US
Telephone Number : 540-536-5100
Fax Number : 540-536-0235
Provider Business Practice Location Address
First Line : 1840 AMHERST ST
Second Line :
City : WINCHESTER
State : VA
Zip : 22601-2808
Country : US
Telephone Number : 540-536-8874
Fax Number : 540-536-7847
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/23/2005
Last Update Date : 05/28/2021

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