Provider Demographics
NPI:1407085699
Name:BEAUBOEUF, ANNE-LISE (MD)
Entity Type:Individual
Prefix:
First Name:ANNE-LISE
Middle Name:
Last Name:BEAUBOEUF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ALBION ST
Mailing Address - Street 2:SOUTHWEST COMMUNITY HEALTH CENTER,INC
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2804
Mailing Address - Country:US
Mailing Address - Phone:203-332-3155
Mailing Address - Fax:203-330-6008
Practice Address - Street 1:46 ALBION ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2602
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-330-6007
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008043127Medicaid
CT008043127Medicaid