Provider Demographics
NPI:1447206859
Name:BOUCHARD, MATTHEW P (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:BOUCHARD
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 1:620 HOWARD AVE
Mailing Address - Street 2:ALTOONA REGIONAL HEALTH SYSTEM
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4899
Mailing Address - Country:US
Mailing Address - Phone:814-889-2866
Mailing Address - Fax:814-889-6785
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4899
Practice Address - Country:US
Practice Address - Phone:814-889-2866
Practice Address - Fax:814-889-6785
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069555L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA926133OtherBLUE SHIELD
PA102194588Medicaid
PA926133OtherBLUE SHIELD
H32159Medicare UPIN