Provider Demographics
NPI:1083685366
Name:BOULANGER, PHILIP C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:C
Last Name:BOULANGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22802-8374
Mailing Address - Country:US
Mailing Address - Phone:804-389-2606
Mailing Address - Fax:
Practice Address - Street 1:5911 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2219
Practice Address - Country:US
Practice Address - Phone:804-213-0259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057867207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001514Medicare PIN
VAI42902Medicare UPIN