MEDICARE: CAROLE-ANNE BOULDIN 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
1	207L00000X	Anesthesiology Physician	M9874	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BP1-0022610	OTHER		INSTITUTIONAL PERMIT

General Provider Information

NPI Number	:	1609087519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE-ANNE BOULDIN MD

Provider Business Mailing Address
First Line	:	101 WESTERN BREEZE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76126-6059
Country	:	US
Telephone Number	:	214-914-4712
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 WESTERN BREEZE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76126-6059
Country	:	US
Telephone Number	:	214-914-4712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	03/27/2018

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