Provider Demographics
NPI:1598830606
Name:BOUCHEREAU, CHANEL G (MD)
Entity Type:Individual
Prefix:MR
First Name:CHANEL
Middle Name:G
Last Name:BOUCHEREAU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:300 STAFFORD STREET
Mailing Address - Street 2:SUITE 113
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3581
Mailing Address - Country:US
Mailing Address - Phone:413-737-9746
Mailing Address - Fax:413-739-1320
Practice Address - Street 1:300 STAFFORD STREET
Practice Address - Street 2:SUITE 113
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3581
Practice Address - Country:US
Practice Address - Phone:413-737-9746
Practice Address - Fax:413-739-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2010-04-12
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Provider Licenses
StateLicense IDTaxonomies
MA45636208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10754OtherHNE
MA0166014Medicaid
MAN51761OtherBLUE CROSS
868094Medicare UPIN
MA10754OtherHNE