Provider Demographics
NPI:1124001797
Name:BOUYEA, MICHELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:BOUYEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 RIVER RD
Mailing Address - Street 2:#299
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1171
Mailing Address - Country:US
Mailing Address - Phone:877-476-6642
Mailing Address - Fax:914-819-0061
Practice Address - Street 1:1000 SALEM RD
Practice Address - Street 2:SUITE B
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-2852
Practice Address - Country:US
Practice Address - Phone:877-476-6642
Practice Address - Fax:914-819-0061
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07317700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8739901Medicaid
NJP00953298OtherRR MCR PTAN
NJ078592A01Medicare PIN
NJ8739901Medicaid
G36838Medicare UPIN
NJ078592DBHMedicare PIN
NJ078592L2BMedicare PIN