Provider Demographics
NPI:1467524884
Name:BOULANGER, NANCY R (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:R
Last Name:BOULANGER
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15314207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM8400Medicare ID - Type Unspecified
MM840001Medicare PIN
ME268450099Medicaid
ME3240685OtherAETNA
MEH01696OtherHPHC
MEH01696Medicare UPIN
MEM103517OtherCIGNA
ME050075889Medicare ID - Type UnspecifiedRAILROAD
ME038837OtherANTHEM
NH30201095Medicaid