Provider Demographics
NPI:1790751667
Name:BOUCHARD, GLEN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:MICHAEL
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1619
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:40 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1138
Practice Address - Country:US
Practice Address - Phone:413-284-5308
Practice Address - Fax:413-284-5413
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000446207P00000X
MA78416207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT930000235Medicare ID - Type Unspecified
CT930001224Medicare ID - Type Unspecified
CTF68904Medicare UPIN