Provider Demographics
NPI:1144429564
Name:PHILIP CHARLES BOULANGER
Entity Type:Organization
Organization Name:PHILIP CHARLES BOULANGER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BOULANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-389-2606
Mailing Address - Street 1:9401 FERNLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1311
Mailing Address - Country:US
Mailing Address - Phone:804-389-2606
Mailing Address - Fax:804-747-0643
Practice Address - Street 1:9401 FERNLEIGH DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1311
Practice Address - Country:US
Practice Address - Phone:804-389-2606
Practice Address - Fax:804-747-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001514OtherMEDICARE GROUP#